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Introduction: Research suggests an association between psychopathy and rape myth acceptance (RMA). Prior to the perpetration of sexual violence, many people hold attitudes that justify, defend and minimize violence. In this case, it would be useful to understand the extent to which myths about rape relate to psychopathy and its various facets. This is the first review which has systematically reviewed the evidence for the relationship between both primary and secondary psychopathy and RMA. Aims: This systematic review and meta-analysis aimed to examine the evidence for i) the relationship between primary psychopathic traits and RMA and ii) the relationship between secondary psychopathic traits and RMA. Method: Systematic searches of nine databases were performed, using search terms relating to psychopathy and RMA. Articles which reported zero-order correlations specifically for primary and secondary psychopathy and RMA were included. Two meta-analyses were conducted to synthesise effect sizes for both primary and secondary psychopathy and RMA. Results: Thirteen peer-reviewed studies were included in the meta-analyses. A significant small association was found between primary psychopathy and RMA, r =0.26 (95% CI [0.19, 0.33] p < .001). A significant small association was found between secondary psychopathy and RMA, r = 0.25 (95% CI [0.20, 0.29] p < .001). Conclusion: Both primary and secondary psychopathic traits are significantly associated with RMA. Researchers should begin to address the methodological and philosophical issues that surround both the fundamental constructs of psychopathy and rape myths, to inform future therapeutic interventions.

Subjective wellbeing (SWB) refers to an individual's perception of their psychological, emotional and social wellbeing (Keyes, 2002). Persecutory ideation refers to thoughts that an individual will come to harm due to the deliberate intention of other people (Freeman & Garety, 2000). These thoughts are common in the general population. Persecutory ideation has been found to be experienced by up to 18.6% of people per year (Freeman et al., 2011). Persecutory delusions are experienced by 90% of people experiencing first episode psychosis (Moutoussis, Williams, Dayan & Bentall, 2007) and have been associated with distress and poorer clinical outcomes (Freeman, 2016). Several theories of the development and maintenance of persecutory ideation have been proposed. Social factors such as insecure attachment, neglect and physical abuse have been found to be associated with persecutory ideation in clinical and non-clinical samples (Bentall, Wickham, Shevlin & Varese, 2012; Pickering, Simpson & Bentall, 2008; Sitko, Bentall, Shevlin & Sellwood, 2014). Cognitive mechanisms have also been found to be associated with persecutory ideation, including reasoning biases (Garety & Freeman, 1999) and worry (Freeman et al., 2012). The overarching aim of the present thesis is to provide a thorough review and empirical investigation of the complex relationship between persecutory ideation and SWB. Chapter one: The first chapter of this thesis is a systematic review that aimed to investigate the relationship between persecutory ideation and SWB. Due to the variation in terminology used within the literature, studies investigating the relationship between persecutory ideation and the related concept of quality of life (QoL) are also included in the review. In particular, the review sought to answer whether people with higher levels of persecutory ideation have lower levels of SWB. Additionally, it considered whether the relationship between persecutory ideation and both SWB and QoL differs between people whose persecutory ideation is classified as "delusional" and those with lower levels of persecutory ideation. Lastly, it sought to identify variables that influence this relationship. Overall, a moderate negative correlation was found between persecutory ideation and both SWB and QoL, in people with and without a history of mental health difficulties. There was some evidence that this relationship may be stronger in people experiencing non-clinical levels of persecutory ideation, compared to individuals experiencing psychosis. A dearth of literature investigating psychological mechanisms that influence the relationship between persecutory ideation and SWB or QoL was found. Chapter two: The second chapter of this thesis is an empirical paper that aimed to investigate the psychological factors that influence the relationship between persecutory ideation and SWB in the general population. It considered the role of persecution deservedness (believing that perceived persecution is deserved), cognitive fusion (being entangled with one's thoughts and believing them as fact) and sense of coherence (feeling one's environment is understandable, manageable and meaningful) in this relationship. A new conceptual model of these factors was proposed and tested. A negative relationship between persecutory ideation and SWB was found. Sense of coherence was found to predict SWB, beyond the level of persecutory ideation. Additionally, people who have accessed mental health services had higher levels of persecutory ideation and lower levels of SWB than people with no history of mental health difficulties. No significant interaction effects were found and therefore the findings did not support the proposed conceptual model. Overall conclusions: There is strong evidence that there is a negative relationship between persecutory ideation and both SWB and QoL, in both clinical and non-clinical samples. It may be beneficial to consider specific psychological interventions to reduce persecutory ideation in people accessing mental health services, regardless of their diagnosis. Wider interventions could be considered to improve SWB and QoL related to persecutory ideation in the general population. These may target experiences and mechanisms that have been found to be associated with the development of persecutory ideation. Further research is needed to investigate other psychological factors that may influence the relationship between persecutory ideation and both SWB and QoL. Sense of coherence is one factor that has been found to be related to SWB, so may be helpful to consider when providing psychological interventions to individuals experiencing persecutory ideation.

The experience of hallucinations is one of the symptoms used in the diagnosis of a psychiatric disorders such as schizophrenia. Functional and structural neuroimaging studies consistently link hallucinatory experience with abnormalities in brain areas supporting normal processing such language areas in auditory verbal hallucinations (AVH) and visual sensory areas in visual hallucinations (VH). Hallucinations are not confined to clinical populations, but are also relatively frequent in the general population. Finding that healthy individuals experience hallucinations without distress has led to models proposing that hallucinatory experiences lie on a continuum, which spans healthy and clinical populations. Continuum models (e.g., Baumeister et al., 2017) provide a theoretical framework with testable hypotheses, that predict brain functional activation, morphometrics or microstructural alterations in the healthy hallucinator group from existing data in the clinical group. Healthy hallucinators therefore may be a key resource in informing transdiagnostic research into the neurological cause of hallucinations. The aim of the current study is to test whether hallucination proneness predict a wide range of multi-modal neuroimaging measures in a large, healthy population. The Launay-Slade Hallucination Scale modified by Morrison’s et al. (2000) LSHS(M) scale as well as auditory (LSHS(A)) and visual (LSHS(V)) subscales were used as a regressors in structural (VBM and FreeSurfer based morphometrics), functional (fMRI) and microstructural (DTI diffusivity and tractography) neuroimaging experiments to test whether alterations seen in patients translate into the healthy population. The morphometric analysis of structural data showed a significant positive correlation between brain thickness in the temporal cortex (bilateral transverse temporal gyrus) (TTG) and LSHS(M) scores. Functional activation data shows a significant positive correlation between LSHS(A) scores and activation in irrelevant task activation (audio/visual) in right (inferior frontal gyrus, superior temporal gyrus and middle temporal gyrus). DTI diffusivity analysis showed that reduced mean diffusivity (MD) in the right inferior longitudinal fasciculus (ILF), superior longitudinal fasciculus (SLF) and occipital lobe (OL), also reduced axial diffusivity (AD) in the bilateral (SLF) and (OL) were linked to higher LSHS(M) scores. The arcuate fasciculus (AF) analysis showed that reduced diffusivity in the left (MD) and left (AD) were linked to high LSHS(M) scores. It is striking that, for this healthy population, the effects observed are the opposite of what might have been expected (continuum theory) for brain pathology and contrasts with previously published data for schizophrenia patients suffering from hallucinations. Finding consistent results using multiple imaging modalities in overlapping brain areas and for a relatively large population makes methodological differences or sampling effects an unlikely explanation for the results. The continuum hypothesis of hallucination assumes that psychotic symptoms, such as AVH and VH, which are experienced in clinical and non-clinical populations, have a common cause. In neuroimaging terms this means that similar functional, structural, and microstructural parameters would be expected for clinical and non-clinical populations show the same direction of differences. Our data does not fit well with this model. However, the results failed to prove that. Studying hallucinatory experiences in a healthy population is attractive because it avoids confounding effects, ranging from childhood trauma, medication or hospitalization. Our data suggests that studies in healthy individuals may not provide data that easily extrapolates to the causes underlying schizophrenic hallucinations.

Objective: People acting in a caring role can experience elevated levels of distress. This study aimed to investigate the feasibility of conducting a clinical trial evaluating Acceptance and Commitment Therapy (ACT) to increase psychological flexibility and reduce psychological distress in informal carers of people who have experienced an episode of psychosis. Participants: Fifteen participants consented to participate in a four-session ACT group intervention and completed questionnaires at baseline and post-intervention. Design: A feasibility study design was employed (Phase 1) based on the PICO framework. This was followed by a focus group (Phase 2) that was analysed using thematic analysis. Measures: The following assessment measures were completed at baseline and at post-intervention assessment points: the Mental Health Continuum-Short Form, the Valued Living Questionnaire, the General Health Questionnaire, the Zarit Burden Interview, the State Version of the Cognitive Fusion Questionnaire, the Experiential Avoidance in Caregiving Questionnaire and fear of recurrence of psychosis was measured by two idiographic Likert scales. The facilitators fidelity to the ACT model was measured via the ACTs of ACT Fidelity Scale. Results: The study was found to be feasible, and both acceptable and helpful to participants. Of those that started the intervention (n=12), 60% were retained throughout the study. Results indicate promising treatment effects across all outcomes, with particular improvements in general levels of distress and cognitive fusion. Conclusion: This is the first study to explore the use of ACT for carers of people with psychosis. Due to the promising results for feasibility, acceptability, satisfaction and initial treatment effects, a pilot randomised trial is now warranted to explore efficacy of the intervention.

This is an explorative and qualitative research study that uses critical and reflexive ethnographic methods (Denzin and Lincoln, 2002). It explores the dance artist’s role in participative and somatic dance, recognising dance as a culturally constructed mode of human action (Buckland, 1999, p. 4). The dance artist is often under-represented and largely invisible in the dance-health literature. This study contributes to this gap in knowledge by exploring the embodied and intersubjective experiences of a group of independent dance artists practicing in a specific, creative, social, and cultural dance domain. Data was collected by adopting an ethnographic attitude of ‘being there’ (Geertz, 1988, p. 1) and embedding myself, as the researcher, in the field of study for a 12-month period. I engaged in a self-critical and self-conscious analysis (Etherington, 2004), thereby making explicit my orientations and assumptions as a researcher with a background in health care and occupational therapy. This is therefore an inter-disciplinary study exploring the potential transfer of knowledge between arts and health sectors. Data gathering methods included participant listening, observation and felt body experience to further understanding of the dance world experienced by this group of dance artists. Data was analysed using primarily ethnographic content (Glaser and Strauss, 1967), and some narrative thematic analysis (Riessman, 2003, 2008) of the dance artists’ partial life stories. The study findings suggest that social and intersubjective relations are key in this dance-health practice in enabling the dance artists, acting as Guides, to facilitate a heightened awareness of somatic and subjective lived body experience. The dance artists empower others to translate and find meaning, as they transition between different mind-body experiences. Corporeal learning and acculturation take place by participating in the creative dance practice, which both reflects and influences everyday life (Koff, 2005). This experience of embodied transformation is understood from the perspective of a salutogenic approach to health (Antonovsky, 1996) with an emphasis on capability, meaning and a sense of coherence. This is exemplified by a sense of congruence between the dance participants’ inner and outer physical experience (Blackburn and Price, 2007, p. 69). Essentially, the body is explored within a specific group of dance artists situated in a particular social and cultural dance-health setting. This doctoral research therefore seeks to bring embodiment before the sociological gaze (Crossley, 2007, p. 80) exploring the subjective and intersubjective lived body experience from a social perspective.

Literature review: Background: Drug use is a problem that has a significant health impact on individuals and financial impact on society. Time perspective, the extent to which individuals focus on the past, present, and future, has been shown to have a significant impact on health-harming and health-protecting behaviour. Objectives: The main aim of the present review was to investigate the relationship between time perspective and drug use. It aimed to investigate which time perspectives, past, present, and future, are associated with increased or decreased drug use. It also aimed to investigate the relationship between time perspective and the way that people think about drugs and drug use (drug use cognitions). Methods: A systematic search strategy was used to identify all the available empirical research that has investigated the relationship between time perspective, as measured by the Stanford time perspective inventory or the Zimbardo time perspective inventory, and drug use. Thirteen studies met the inclusion criteria for review. Results: Results suggest that individuals with higher future time perspective are less likely to use illicit drugs. They are also likely to hold negative attitudes towards drug use. Individuals with higher present time perspective are more likely to use drugs, and to use them more frequently and in greater quantities. They are also more likely to hold positive views about drug use. Conclusions: There is emerging evidence to suggest that increased future time perspective is protective against drug use while increased present time perspective represents a risk factor for drug use. Empirical paper: Research suggests that time perspective, the extent to which individuals focus on the past, present, and future, might play a significant role in predicting aggression. However, research in this area has typically conceptualised and measured aggression as a unitary construct. No research has, to date, considered the relationship between time perspective and clinically important subtypes of aggression: reactive-proactive and impulsive-premeditated . The present study examined whether reporting an increased deviation from a balanced time perspective, reflecting the extent to which individuals can cognitively switch between past, present and future time perspectives, predicts increased reactive and proactive aggression, and impulsive and premeditated aggression. A sample of 389 adults completed measures of aggression, time perspective and emotion regulation. As expected, proactive and premeditated aggression, which are characterised by the planned use of aggression, were not associated with an increased deviation from a balanced time perspective, suggesting that these subtypes of aggression are not associated with difficulty switching between past, present and future time perspectives. Reactive and impulsive aggression, which are characterised by unplanned, impulsive aggressive outbursts, were found to be associated with an increased deviation from a balanced time perspective, suggesting that these aggressive subtypes are associated with increased difficulties switching between time perspectives. Contrary to expectations, however, an increased deviation from a balanced time perspective was not clinically predictive of increased reactive or impulsive aggression when controlling for a range of emotion regulation abilities. Clinical implications and areas for future research are discussed in relation to the study findings.

Types of homelessness are wide-ranging and can include street homelessness, staying in temporary accommodation like shelters or hostels, and unsuitable accommodation like squats, tents or other temporary dwellings (Bramley, 2017). A vast amount of time, money and resource has been allocated to determine the causes of homelessness, but the problem persists. A recent count of rough sleepers in the United Kingdom shows a rise of 134% over the preceding six years (National Audit Office, 2017). For the homeless individual, the realities of being unhoused are in stark contrast to the average housed individual: increased risk of long-term physical health problems (Homeless Link, 2014), cognitive and neurological impairments (Backer & Howard, 2007), and mental health difficulties (Rees, 2009). Homeless individuals are also at great risk of physical and sexual assault (Breakey & Fisher, 1990) and more likely to develop suicidal thoughts and behaviours over time than the general population (Eynan et al., 2002). There are systemic consequences of homelessness, including an increased spend by health services; an estimated £85 million per year (Department of Health, 2010). Despite various strategies to both prevent and intervene, homelessness remains a significant problem for health and social care agencies and a challenging moral dilemma for society. Although there is a significant body of research examining the antecedents of homelessness, the multi-dimensional and systemic factors that can lead to a person becoming homeless are often denied or minimised. This can create a situation where society perpetuates the problem of exclusion that it seeks to alleviate (Jordan, 1996; Wilkinson & Pickett, 2009; Cooper & White, 2017). This can lead to demoralisation and disappointment among front line support staff working in services (Adlam, Kluttig, & Lee, 2018). Responses to lack of success in services reaching out can vary but can lead to the individual retreating further from reach (Armstrong, 2018) and services becoming increasingly difficult to access (Fitzpatrick & Pleace, 2012). The systematic literature review (Chapter One) sought to explore the contribution of the Capability Approach to the provision of mental health services. The Capability Approach is a human development framework which has contributed to the advancement of social justice and a recognition of the interaction of micro, meso and macro factors on an individual’s health and wellbeing around the world (Nussbaum, 2011). The application of the approach to mental health is more recent, and to date, there has not been a comprehensive exploration of how this approach has been applied to mental health services. The research paper (Chapter Two) addressed the experiences that formerly homeless individuals had in seeking help and support, and also asked professionals working in homeless services what it was like to provide services to homeless people. The systemic barriers and individual challenges were discussed. A qualitative methodology was used to capture the experiences of both groups of participants, using 1:1 interviews for individuals with lived experience, and focus groups with professionals.

Evidence suggests that emotional distress, including problems like depression and anxiety is commonly reported by individuals meeting criteria for psychosis spectrum disorders. It has been argued that the appraisals individuals hold about the meaning of their psychosis may explain the emotional distress experienced. However, this literature has often failed to acknowledge the role of other variables in accounting for this distress. The aim of this thesis was to investigate the mechanisms underpinning emotional distress in those experiencing psychosis, by focusing specifically on psychosis-related appraisals and goal expectancy. A total of five studies are reported, four of these addressed the above aim by focusing specifically on individuals with a psychosis related disorder who were receiving support from a rehabilitation service. The final study captured how parental carers make sense of their child’s future following an experience of psychosis. Following a review of the literature in Chapter One, Chapter Two aimed to provide an overview of the methodological approaches employed in the current thesis. The study presented in Chapter Three aimed to synthesis the literature investigating the association between appraisals of psychosis experience and emotional distress in those experiencing psychosis, in order to determine the direction and magnitude of this association. A total of 17 studies were included in the review (15 in the meta-analysis). Small to moderate associations were observed between appraisals of psychosis and both depression and anxiety. A narrative synthesis of the literature showed that significant associations were evident in a small number of longitudinal studies (with regards to depression only). Furthermore, i in a number of cross-sectional studies significant associations held even when accounting for symptoms of psychosis, suggesting that the association that beliefs have with distress may not be entirely explained by the shared association with psychosis symptom severity. Chapter Four presents the findings of a study that aimed to validate a goal generation task within individuals experiencing psychosis. Using behaviour sequence analysis, the utility of the task in capturing goal generation processes in those meeting criteria for psychosis was determined. The study highlighted that those experiencing psychosis were able to progress from lower to higher-order goals. Using a cross-sectional design, Chapter Five aimed to investigate the extent to which psychosis related appraisals and goal expectancies (goal likelihood and goal difficulty) could account for emotional distress in those experiencing psychosis. A total of 73 individuals accessing support from a rehabilitation service were recruited. Results revealed that appraisals of psychosis were significantly associated with depression and anxiety. Specifically, appraisals of psychosis as a source of internal shame and defectiveness, external shame and as resulting in loss (e.g., loss of future employments) were all found to predict both depression and anxiety. Many of these associations held when controlling for other variables. Only appraisals of internal shame and defectiveness were found to be significantly associated with emotional distress, however, this association did not hold when controlling for other variables. When adjusting for appraisals of psychosis, goal appraisals were not found to be significantly associated with emotional distress. Chapter Six aimed to expand upon the results presented in chapter five by investigating the longitudinal association between goal expectancies (goal likelihood, difficulty and progress) and emotional distress. A series of mixed model ii regression analyses were carried out to determine the concurrent association between the variable and to establish if the degree of change in goal appraisals would correspond with changes in depression scores. On the whole these models revealed that goal expectancies do not have a consistent association with emotional distress when adjusting for other factors. However, they did highlight that appraisals of psychosis may be implicated in emotional distress within individuals experiencing psychosis. Finally, Chapter Seven presents the findings of a qualitative paper. Nine parental carers were interviewed with the aim of exploring how they make sense of their child’s future following an experience of psychosis, focusing particularly on the goals and aspirations parental carers hold for their adult children. An interpretative phenomenological analysis was carried out. A total of three superordinate themes emerged, impact of psychosis (subthemes: psychosis causing a change of path, goals: lost, maintained and adjusted), a fear of relapse (subthemes: concerns about coping and adjustment), and navigating the future (subthemes: hope, uncertainty and somewhere in between, barriers and facilitators). Overall, the findings from the current thesis suggest that appraisals of psychosis experience are important in accounting for emotional distress, an effect that was observed consistently across the studies reported within this thesis. However, it appears that goal expectancies do not have a consistent effect with emotional distress.

Childhood and adolescence are important developmental phases that influence health and well-being across the life span. Social relationships are fundamental to child and adolescent development, yet studies have been largely limited to children’s relationships with other humans. Whether pet ownership can exert similar developmental health benefits during childhood is largely unknown. The main aim of this thesis was therefore to investigate the impact of pet ownership on the development in children and young people. This thesis provides an evidence review of the current literature, and an investigation of the potential associations between pet ownership and emotional; behavioural; cognitive; educational; and language development outcomes, using the analysis of a large cohort dataset, the Avon Longitudinal Study of Parents and Children (ALSPAC). The review found that pet ownership and the significance of children’s bonds with companion animals have been underexplored within child development, and there was a shortage of high quality and longitudinal studies that controlled for confounding. This thesis aimed to address this research gap in the field using ALSPAC data, and in addition, to make an original contribution to knowledge by investigating developmental outcomes that had not yet been previously explored. Data was collected and analysed from approximately 14,000 families via parental and child reports, and clinic assessments. Analyses were adjusted for a wide range of potential confounders, including demographic and socio-economic variables, and to maximise data usage, missing data techniques were applied. Univariable and multivariable logistic and linear regression analyses were carried out to assess associations between pet ownership (any pet, dog, cat, other) and developmental outcomes. Outcomes investigated were: emotional health (self-esteem, anxiety and depression); behavioural outcomes (emotional difficulties, hyperactivity, conduct difficulties, peer problems and prosocial behaviour); cognitive development (attention, impulsivity and memory); educational attainment (KS1, KS2 and GCSE); and language development (comprehension, vocabulary, social development and non-verbal communication) in childhood. Within emotional health, evidence of an association was found between owning any pet or a cat, and a lower self-esteem (scholastic competence) at age 8. Further associations were found between any pet or other pet ownership and higher odds of social anxiety at age 7. Within behavioural development, cat ownership was associated with increased odds of hyperactivity at age 3. Owning any pet, or a cat at age 3, and owning a dog at both ages 3 and 11 was associated with increased conduct disorder. However owning dogs or other pets was associated with a lower likelihood of experiencing prosocial difficulties at age 3, and owning other pets was associated with fewer peer problems at age 11. Owning other pets at age 11 was also associated with fewer total behavioural difficulties at age 11. Within cognitive development, dog ownership was associated with poorer attentional switching at age 11. Pet ownership was consistently associated with lower educational attainment in a number of different subjects across ages, despite adjustment for logical confounders. Lastly, pet ownership was associated with a higher score in language comprehension at age 5, and a higher non-verbal communication score at age 2. This thesis finds no clear patterns across developmental outcomes, pet types or child age in the ALSPAC dataset. Pet ownership does not appear to be associated with improved emotional health, cognitive or educational development of children. Owning pets may however, have a positive impact on social development as seen through the positive associations in language development and prosocial behaviour. This thesis demonstrates the importance of using large, well-designed longitudinal studies that control for key confounders. Future research needs to incorporate age-appropriate pet attachment or pet bonding measures into future cohort studies in order to determine whether the relationships we have with our pets are of more importance than pet ownership in conferring developmental benefits.

Self-injury, also known in the literature as non-suicidal self-injury (NSSI), self-mutilation, parasuicide and deliberate self-harm, occurs when an individual causes intentional harm to self without the intent to end their life, most commonly by cutting (Hawton Rodham, Evans & Weatherall, 2002). The United Kingdom (UK) has had the highest rate of self-injury in Europe, with an estimate of 400 in 100,000 people engaging in self-harm (Horrocks, House & Owens, 2002). Self-injury is an ongoing concern and remains prevalent, particularly amongst young people. There are many reasons why someone may self-injure, and for those who repeatedly use self-injury the reasons (and methods) may be different each time (Horrocks, Price, House & Owens, 2003). Adverse life events are considered to play a key role in self-injury. For example, past trauma (e.g. sexual abuse) may be an important reason why someone starts to self-injure and adverse life events (e.g. relationship breakdowns) may precipitate further acts of self-injury (Haw & Hawton, 2008). De Leo and colleagues (1999) also found a relationship between physical illness and increased self-injury. Other risk factors include disadvantaged socioeconomic status, mental health diagnoses, substance use, sexual orientation, ethnicity and gender such as Asian females, poor problem solving skills and learning disabilities (NICE, 2012). Chapter one presents a systematic review of the quantitative literature available from searching databases using key terms relating to self-injury and attachment. A key aim of chapter one is to establish whether there is a relationship between insecure attachment and non-suicidal self-injury (NSSI) in adults. Synthesising the relevant research in this way aims to provide additional insight and value to existing literature, as the findings of this review indicate there may be a relationship between experiences of insecure attachment and self-injury. Additionally, research has identified that early trauma, abuse and emotional neglect are risk factors for self-harm, shame, self-criticism and fear of compassion (Gilbert, 1992, 2005, 2007; Andrews, 1998), concepts which are examined in Chapter 2. Attachment can be defined as the biological bond between a child and caregiver, which is fundamental to survival and development. Attachment theory highlights the importance of the quality of the relationship a baby and/or young child has with their primary care giver and the long lasting effects that these relationships can have upon the individual's future mental health and adult relationships. Severe disruptions in the attachment relationship have been considered as a form of 'trauma' (Allen, 2013). Attachment trauma is defined as the disruption in the important bonding process between child and caregiver; for example following abuse, neglect, lack of affection and absence of care (BrightQuest, 2019). These early relationship experiences can be distressing for a young child and are found to play an important role in the underdevelopment of skills relating to emotion regulation, problem solving and mentalizing (Fonagy & Bateman, 2007; Fonagy, Gergely, Jurist & Target, 2002). These are areas that individuals who self-injure often experience difficulties with (Bateman & Fonagy, 2004; Walker, Hirsch, Chang & Jeglic, 2017). Research has however found that people who self-injure tend to use this coping method for a limited period of time, with the majority spontaneously stopping by early adulthood (Moran et al., 2012). The act of self-injury may be time limited, however the physical scars associated with self-injury are often permanent and may have a significant ongoing impact on an individual's life. The majority of research and clinical guidelines in this area focus on current self-injury and risk, rather than potential resulting longer term difficulties. Research on the impact of self-injury scarring is somewhat limited. For example, the National Institute for Heath and Care Excellence (NICE) guidelines for the short-term management of self-harm in over 8 years does mention the importance of minimising scaring (p. 25; NICE, 2004). However scar minimisation is not mentioned at all in the long term management of selfharm, with the focus on monitoring and treatment to reduce or stop self-injury (NICE, 2011). Chapter two therefore aims to provide insight and additional research into the longer-term impact of self-injury, by exploring the psychological and social factors in individuals who have physical scars as a result of previous self-injury. Previous studies by Gilbert and colleagues (Gilbert et al., 2010 and Gilbert, McEwan, Matos & Rivis, 2011) identified that individuals who self-injure report high levels of shame, self-criticism and a fear of engagement in compassionate behaviours, often as a result of early childhood experiences. It has also been suggested that when scars result in feelings of anxiety and shame the NSSI recovery process can be hindered (Lewis, 2016). Shame has been defined as the painful feelings of humiliation or distress, often caused by the consciousness of wrong or foolish behaviour (Oxford, 2019). Shame can be experienced both externally when an individual believes or experiences a negative view of themselves in the minds of others and internally when an individual has negative self-evaluations (Gilbert et al., 2010). When facing adversity, individuals can become either self-critical or self-reassuring (Gilbert, Clarke, Hempel, Miles & Irons, 2004). Individuals who are self-critical can believe that they are inadequate and inferior, and/or they can feel self-disgust and self-hatred. This can be for two reasons, to be either self-corrective or self-punishing (Gilbert et al., 2004). The Cambridge Dictionary (2019) defines compassion as a strong feeling of sympathy and sadness for the suffering or bad luck of others and a wish to help them. It captures attributes of kindness, care, empathy and non-judgement, which can be directed towards (or from) others and for ourselves in times of difficulty (Gilbert et al., 2011). However, some individuals have difficulty in developing or expressing compassion due to avoidance or fear reactions (Gilbert, 2010). In the current study, a series of measures were used to determine which factors relating to shame, selfcriticism and fear of compassion contributed to psychosocial adjustment scores in individuals who no longer self-harm but still have scarring. Findings indicated that a number of significant predictors helped to explain or contribute to psychosocial adjustment in these individuals. For example: a) depression, b) the age an individual stops self-injuring, c) the individual's overall opinion of the scars in comparison to normal skin (severity), d) the individuals current age and e) the fear of expressing compassion to others scores explained 42% of the social factors (such as employment, leisure activities and close relationships) relating to adjustment. From a psychological perspective: a) level of depression, b) anxiety, c) the number of years an individual has self-injured, d) current age, e) whether an individual feels ashamed about specific personal characteristics not related to body or behaviour (characterological shame), f) whether an individual can be self-reassuring (by having the ability to focus on positives and reassure themselves when things do not go right), and g) whether someone is able to express kindness and compassion to themselves explained 75.2% of the psychological factors (such as thoughts and feelings about life). It is hoped that the results of the study will inform clinical practice by identifying which key predictor variables contribute to psychosocial adjustment in individuals who have scars as a result of previous self-injury.

Individuals experience psychosis when their thoughts and emotions are so impaired that they lose touch with reality. Psychosis consists of many symptoms, of which paranoia is the most common. It is important to assess the structure of paranoia as, should paranoia exist on a continuum, examining paranoia in general population samples may inform interventions and preventative strategies for individuals who experience clinical levels of paranoia. Research has consistently shown that elevated rates of paranoia, and psychosis in general, are apparent in ethnic minority populations in Britain. Here, paranoia will be assessed in various community samples using the Social Identity Approach (SIA). The SIA was developed to explain intergroup relations and consists of the Self-Categorisation Theory (SCT) and the Social Identity Theory (SIT). The SIT was recently posited to explain the higher rates of psychotic symptoms, such as paranoia, in immigrant and ethnic minority populations. It suggests that the elevated rates of mental illnesses in these groups are a result of social identity processes. As detailed in Chapter 1, many other explanations have been made to explain the high rates of psychotic symptoms in majority and minority populations. These will be discussed but the focus of Chapter 1 will be the SIA, in particular the SIT. The four empirical studies in my thesis examined the latent structure of paranoia and the relationship between social stressors, social identities and paranoia in majority and minority populations. In Chapter 2, I synthesised research on the structure of paranoia and critiqued the methodology used in previous studies. In Chapter 3, using data from the general population, individuals with an at-risk mental state (ARMS) and individuals who had been clinically diagnosed, I assessed the latent structure of paranoia using up-to-date taxometric methods. My findings strongly supported previous research that paranoia is best represented by a continuum rather than a taxon. In Chapter 4, I discussed the application of the SIA to explain levels of paranoia in the community. Specifically, I proposed that identifying with social groups can buffer people against paranoia that is associated with social stress. In Chapter 5, I examined this suggestion in a general population sample. I investigated whether the relationship between financial stress and paranoia was mediated by self-esteem and whether neighbourhood identification moderated this relationship. I assessed the same relationship in students who moved away from home to attend university, specifically testing the protective value of their current host town identity and their previous hometown identity. My results suggested that strong neighbourhood identification protected people in the general population from paranoia associated with financial stress by furnishing them with self-esteem. The same effect was observed for students when they identified with their new host town but not their previous hometown. Thus, highlighting the importance of identifying with one’s local community in order to mitigate the effects of stress on paranoia. In Chapter 6, I applied the SIA to ethnic minority populations and discussed the role of negative social interactions (negative contact) in contributing to elevated rates of paranoia. Chapter 7 examined the relationship between negative contact with White British people and paranoia in an African-Caribbean sample and whether this relationship was moderated by British identification. Further, I examined whether the relationship was mediated by self-esteem and/or powerful others locus of control (LoC). The interactive relationship between negative contact and British identification on paranoia was mediated by LoC, but not self-esteem. Specifically, I found that increased negative contact predicted higher levels of paranoia through a stronger powerful others LoC, but only when British identification was strong. In Chapter 8, the importance of perceived discrimination as a risk factor for paranoia and the use of implicit identity measures was outlined. Students who were born in England, and of Pakistani heritage, were recruited in Chapter 9. Their explicit and implicit Pakistani and English identities were tested as moderators of the effect of perceived discrimination on paranoia. Participants’ implicit Pakistani identification moderated the relationship between perceived discrimination and paranoia, such that, high levels of perceived discrimination were associated with high levels of paranoia when implicit Pakistani identification was low. Interestingly, these results fit with the results from Chapter 7 where it was found that identifying with the group that was a source of negative contact (British identity) was associated with high levels of paranoia and in Chapter 9, it appears that identifying with the group that was not the source of perceived discrimination (implicit Pakistani identity) protected against paranoia. In Chapter 10, I integrated and summarised the findings of my studies and examined how they build on previous research. Limitations of the studies were detailed, and clinical and policy implications were discussed. I suggested potential avenues for future research examining stressor-identity-paranoia relationships. Overall, my studies suggest that paranoia exists on a continuum, therefore, assessing paranoia in general population samples may inform interventions and preventative treatments for clinical paranoia. The studies highlight the importance of maintaining strong identification with groups that are meaningful and are a source of positivity, particularly identities associated with one’s local community. However, identifying with the majority culture may be harmful when combined with adverse social experiences within that culture. The findings also emphasise the importance of positive majority-minority intergroup relationships in improving community mental health.

This thesis is comprised of two chapters: 1) a systematic review of longitudinal career outcomes following mentorship programs in academia, for faculty of colour identified as Underrepresented Minority (URM) and 2) experiences of individuals from low Social Economic Status (SES) backgrounds, reaching leadership positions within Clinical Psychology. The systematic and empirical chapters have been written for planned publications in the Journal of Clinical Psychology, these chapters have been written in accordance with the author guidelines (see Appendix 1). The two chapters are individual papers, although share an overarching theme of diversity representation within professional settings. A diverse workforce has numerous advantages within academic and healthcare settings, including fostering creative ways of thinking and understandings towards the needs of marginalised individuals (Kline, 2014). Both chapters explore underrepresented professional populations and both chapters explore longitudinal career paths. The literature review focuses on academics of colour as initial literature searches on longitudinal career outcomes yielded sufficient data to conduct a review in this population; in contrast there was limited research available assessing SES and longitudinal career outcomes. As the latter highlighted the need to explore SES and career outcomes further, the second chapter aimed to explore the career paths of people from low SES backgrounds who have reached leadership positions within Clinical Psychology. This chapter followed on from the review chapter as it allowed us to examine the role of important factors, including mentorship, which play a pivotal role in career progression. A specific focus of Clinical Psychology leaders from a low SES background was taken as 1) this population is underrepresented within the profession (Scior, Williams & King, 2017; Stewart, 2017) and 2) it ensured this doctoral piece of research was specifically relevant to the field of Clinical Psychology. The literature review provides a contemporary synthesis on the effectiveness of mentoring programs by investigating longitudinal career outcomes. A systematic review was conducted and ten eligible studies were reviewed, consisting of quantitative, qualitative and mixed methods design. Across all studies, positive outcomes regarding publication, grant and promotion rates were observed through a longitudinal timeframe. Informal mentoring programs were noted to be advantageous for URM faculty in allowing a greater focus on 'softer skills', such as personal attributes and personal growth. Future research should focus on comparing longitudinal career outcomes of mentoring programs with a matched control group. Particularly, there is a need for more studies conducted in the United Kingdom (UK), as all papers in the review involved a population from the United States of America (U.S.). Research on the specific components of mentoring in the UK, tailored to URM populations, could lead to the development of more nuanced mentorship schemes, which can explore important issues such as intersectionality that can help decolonise current curriculums and be implemented across academic institutes, including Clinical Psychology programmes. The empirical paper explored the personal narratives of twelve individuals from low SES backgrounds, who have reached leadership positions within Clinical Psychology. Data was analysed using Narrative Analysis (NA). NA researchers highlight the space it creates for exploring micro, meso and macro influencers, by the examination of the socio, political and cultural context; which in turn helps develop a greater understanding of individuals' experiences (Weatherhead, 2011). Experiences which emerged from the participants' narratives were presented within the framework of a three-act story, corresponding to a traditional beginning, middle and end. Participants held narratives which integrated interpretations of major life changes and difficult early experiences, such as childhood trauma and abuses of power and reconstructed them to highlight the positive outcomes, i.e. being in a position to passionately champion for and empower vulnerable individuals. In relation to social mobility, participants have developed narratives to negotiate and make sense of their changing circumstances, (within their professional roles this includes working to their values, a strong focus on working hard and gaining confidence to have vulnerable and difficult conversations). Future research should work to develop interventions that can encourage working-class students in their career aspirations, including helping them transition from college to university, through negating some of the barriers embodied as a result of classism, such as improving selfconfidence and creating a space to practise vulnerability.

The overall aim of the current thesis was to improve the understanding of reward and punishment sensitivity or responsivity in CYP (CYP) who display persistent patterns of violent and antisocial behaviour. It is estimated that one in twenty (5.6%) of 5 to 19 year old's have conduct problems, with these rates higher for boys than girls (NHS digital, 2018). These behaviours are a serious concern for public policy and are associated with a host of social, emotional and academic problems for the child or young person (Kimonis & Frick, 2011). Research has found that there is considerable heterogeneity within this group of CYP which creates challenges for developing effective evidence-based interventions (Frick, Ray, Thornton, & Kahn et al, 2014). One approach to delineate this group of CYP is by their affective and interpersonal style, and not the conduct problems themselves. Specifically, research has focused on identifying CYP on the basis of a callous unemotional (CU) interpersonal style or 'trait' which derives from the adult literature of psychopathy (Frick et al., 2014; Hare & Neumann, 2008). CYP with CU traits are characterised by affective and interpersonal problems such as lack of remorse or empathy, callous use of others and shallow or deficient emotions (Fanti, 2013; Frick & Viding, 2009). These CYP represent a group with the most persistent and severe problem behaviours (Burke, Loeber, & Lahey, 2007; Lynam, Caspi, Moffitt, Loeber, & Stouthamer-Loeber, 2007) and it is estimated that between 36% and 55% of CYP accessing the youth justice system have elevated CU traits (Teplin, Abram, McClelland, Dulcan, & Mericle, 2002). CYP with CU traits have been found to show more risk taking behaviours and the mechanism behind this is thought to be due to their responsiveness to reward (Barry et al., 2000; O'Brien & Frick, 1996) and reduced sensitivity to punishment cues (Allen, Morris, & Chhoa, 2016; Fisher & Blair, 1998; Pardini, Lochman, & Frick, 2003). The experience of punishment is usually perceived as negative or discomforting by a child or young person (Kochanska, 1994). However, for CYP with CU traits, they have been found to have a reduced responsivity, level of arousal, and memory for negative stimuli (Anastassiou5 Hadjicharalambous & Warden, 2008; Kimonis, Frick, Fazekas, & Loney, 2006; Sharp, van Goozen, & Goodyer, 2006). This lack of arousal and emotional memory for negative information in relation to reward and punishment responsivity was investigated in Chapter 2. To the author's best knowledge, there has not been a systematic review examining responsiveness to reward and insenitiviy to punishment. In order to address this, Chapter 1 of the current thesis outlines a systemic review of studies investigating responsiveness to reward and insensitivity to punishment in CYP wth CU traits. The findings demonstrated that CYP with CU traits are less responsive (or insensitive) to punishment. However the literature pertaining to reward responsivity was inconsistent. There was a lack of consistency within which reward and punishment responsivity was measured and conceptualised. Furthermore, given the heterogeneity associated with CU traits it was surprising that many studies failed to include or acknowledge subgroups of CU traits. Finally, the review found that CYP with CU traits were insensitive to punishment however there remains little explanation of the mechanism of this relationship. In order to address the limitations documented within the review, Chapter 2 details an empirical study that examined the mechanism behind the relationship between CU traits and responsivity to reward, when there is a possibility of being punished. Specifically the study explored whether emotional memory could explain this relationship. The study used validated measures of CU traits, anxiety and conduct problems. Task based measures were used to assess reward responsivity (when there is a possibility of being punished) and an ecologically valid measure was used to assess emotional memory in a life like setting (The Scenic False Memory Paradigm; Hauschildt, Peters, Jelinek, & Moritz, 2012). Correlation and regression analysis were conducted and no associations were found between CU traits, reward sensitivity or emotional memory. As predicted, high CU traits were related to higher conduct problems. It is believed that with a sample size and greater power, significance would have been reached. Clinical implications regarding the focus of assessment, support and interventions for CYP with CU traits are presented.

This thesis explores human rights on acute mental health wards from the view of health professionals and service users. The theoretical framework chosen is the theory of planned behaviour (Ajzen, 1988; 1991) for which there is an emerging evidence-base for its use with staff teams (Perkins et al., 2007). Mental health professionals' intention to work using a human rights-based approach will be presented, as will service users' perceptions on whether they feel cared for with this approach. The thesis comprises two papers; a systematic literature review and an empirical paper. Alice Donald (2012) from the Human Rights and Social Justice Research Institute has provided an extensive guideline on evaluating human rights-based approaches in health care. Part of a five-year programme in conjunction with the British Institute of Human Rights (BIHR), the Department of Health, and a number of National Health Service (NHS) Trusts, the Human Rights in Healthcare Programme (www.humanrightsinhealthcare.nhs.uk, 2011- 2012) aimed to assist NHS Trusts to put human rights into practice in different areas of their work. The guideline outlines nine case studies of previous evaluations of human rights-based interventions in a range of health care settings. The case studies are predominantly within learning disability, older adult or physical health settings, with one within a high security forensic mental health hospital. There is a lack of evaluation in human rights-based approaches in adult mental health, in particular acute inpatient mental health services. All of the example evaluations published on the programme's website were studied during the design phase of the thesis, with consideration given to how previous work could be adapted for this population. Chapter one is a systematic literature review that aims to explore how the theory of planned behaviour acts as a framework to understand staff team intentions and behaviours towards certain decisions, specifically focussing on staff teams in mental health settings. This chapter does not have a human rights focus, the primary aim is to introduce the psychological theory chosen and understand how it has been implemented in a novel way. Human rightsbased approaches will be introduced in chapter 2. Thirteen papers are systematically identified, quality assessed and reviewed. Data regarding the three constructs of the theory of planned behaviour; attitude, subjective norm and perceived behavioural control, is narratively synthesised. An evaluation into how the theory of planned behaviour can be used to guide intervention is also offered. The review comments on the range of predicting variables and methodologies used in the 13 papers. Results are discussed in detail and limitations and clinical implications are outlined. Chapter two is an empirical paper that uses the theory of planned behaviour in a novel way to explore mental health professionals' intentions to work using a human rights-based approach on acute mental health wards. The paper outlines the process of constructing a theory of planned behaviour measure, the recruitment and data collection process and the quantitative data analysis. It also reports findings from service users' perspectives of their care on acute mental health wards and whether they feel staff support them using a human rights-based approach. This section of the report is a mixed methods design, reporting both categorical quantitative data and qualitative feedback analysed using content analysis. The findings are discussed in relation to existing literature, with the aim of identifying future recommendations and clinical implications. It is important to note that the term 'service user' has been used throughout the thesis to refer to individuals that have experienced an inpatient stay on an acute mental health ward. Using this term keeps the thesis consistently in line with formal documents such as National Institute for Health and Care Excellence guidelines, however there is an understanding that some individuals may choose to use different terms (see McLaughlin, 2009; Simmons, Hawley, Gale & Sivakumaran, 2010). Those who participated in consultation were asked to give their preferred term, resulting in a resounding response for 'patient'. Therefore, the consultation section of the empirical paper is named 'consultation with previous patients'. It did not feel appropriate to use this language throughout the document, as they cannot be considered a collective voice for all individuals with shared experiences.

Cognitive Analytic Therapy is increasingly being utilised in National Health Service (NHS) mental and physical health settings as a framework to understand service users and the possible nature and reasons for continuation of their distress (Ryle, Kellett, Hepple, & Calvert., 2014). The approach combines aspects of cognitive and psychodynamic models of psychotherapy and centres around the concept of 'reciprocal roles', a term used to conceptualise inter- and intra- personal patterns of relating between individuals and within the self (Ryle & Kerr, 2003). The framework is being adapted for clients presenting with a broad range of difficulties (e.g. Wicksteed, 2016; Chanen, McCutcheon, & Kerr, 2014; Hepple & Sutton, 2004), including people with learning disabilities (Lloyd & Clayton, 2014). Despite its prevalence and implementation in clinical services, CAT remains at an early stage in terms of its developing evidence base (Ryle et al., 2014). An array of academic works have developed theoretical and clinically useful guidance documents to inform and shape clinical practice (e.g. Ryle, Leighton & Pollock, 1997; Meadows & Kellett, 2017), however fewer studies have robustly explored how CAT is being implemented within clinical services and considered its effectiveness (Ryle et al., 2014). The present thesis aims to contribute to the evidence base for CAT in more methodically robust and systematic ways. One of the key threads of the thesis is the concept of 'effectiveness', the thesis starts by presenting effectiveness as considered within evidence-based medicine philosophies (see Herbert, 2003) which typically use empirical, psychometric methods of assessment to frame 'effectiveness' as a scientifically and homogenously representative phenomenon. As the thesis progresses, effectiveness is considered from a more 'bottom up' and clinically realistic position. Overall, the thesis raises interesting questions about how effectiveness is understood and implemented in clinical environments. The systematic review and meta-analysis (chapter 1) aims to provide an up-to-date overview of the literature contributing towards the CAT evidence base. This centres around the use of three categories of psychometric assessment measures as a way of considering the overall 'effectiveness' of CAT. By grouping together and statistically combining multiple studies, the review aimed to provide a more statistically powerful commentary on the current status of the developing evidence base. The empirical paper (chapter 2) uses a thematic analysis methodology to explore how clinicians are using CAT within learning disability settings. This builds on existing accounts (e.g. Frain, 2011) which provide descriptions of anecdotal, individual applications of the model. Attempts have been made to describe adaptations for people with ID from the perspective of individual practitioners (Clayton, 2014), but to date, there has been no attempt to more systematically understand how clinicians are adapting their practice. The paper synthesises multiple practitioners' constructions of how they are adapting their practice, understanding the concept of ID and understanding effectiveness. This provides a richer and more contextualised understanding of effectiveness which, to some extent, contrasts with the epistemological underpinnings as presented within the systematic review. The two papers have different target journals: Psychology & Psychotherapy; Theory, Research & Practice is the target journal for the systematic review and the Journal of Applied Research in Intellectual Disabilities for the empirical paper. The chapters conform to author guidelines however, figures and tables along with further contextual information are provided in accordance with thesis guidelines. Author guidelines for the papers are available in appendices (A & G).

The value of personal experience with mental health difficulties is recognised in policy and is increasingly encouraged in practice (Repper, 2013). Despite this, silence around mental health professionals sharing their own mental health difficulties remains a cause for concern, even though evidence suggests those entering such a profession often do so because of their own experiences (Barr, 2006; Sussman, 2007). Narratives in this area are further complicated by the 'experts by experience' concept, which paradoxically plays into a 'them and us' divide (Richards, 2010), locating 'difficulties' in the other, and failing to recognise therapists' own vulnerabilities (Gough, 2011). Historically, therapists sharing personal information about one's self, known as therapist self-disclosure (TSD) was primarily influenced by the therapist's theoretical orientation, with some models (e.g. psychodynamic) arguing that it can impede treatment (Curtis, 1982) by distorting the client's transference and therefore affecting its resolution (Peterson, 2002). Current thinking is converging across theoretical orientations in suggesting that TSD has potential benefits, if used carefully (Eagle, 2011). Regardless of therapist theoretical orientation, both self-stigma and fear of negative evaluation appear to be important factors in therapists' reluctance to speak openly about their own difficulties. Research suggests there are both positive and negative aspects of therapists sharing their own mental health difficulties (Audet and Everall, 2010; Levitt et al, 2016; Wells, 1994). Exploring how the therapist's own clients view this, may help facilitate a greater understanding around personal perspectives on self-disclosure, particularly relating to the perceived interpretations made by others. It may also enhance understanding about what, how and when to share information that may be helpful to disclose during therapy. Therapists have reported feeling more comfortable sharing their own psychological distress with clients than with colleagues or peers (Wright, Seltmann, Telepak & Matusek, 2012). Recent research has suggested that TSD of a therapist's own difficulties in such services is considered more acceptable and viewed as beneficial if done appropriately, with further research needed into TSD for wounded therapists experiencing other mental health difficulties (Cvetovac & Adame, 2017). The narrative review (Chapter 1) endeavoured to explore the existing research relating to clients' experiences of TSD using a range of literature, including published and unpublished studies, case illustrations and review articles. It aimed to synthesise such literature to develop a greater understanding of clients' needs, wishes and views pertaining to TSD to inform current practice and guidance for therapists when considering disclosure decisions. The empirical paper (Chapter 2) addressed the paucity of research in the area relating to clients' experiences of TSD of personal and sensitive information, specifically a mental health condition. The reasons for this were two-fold; firstly, to gain an understanding of what people who have had psychological therapy for their own mental health thought about therapists who have experienced their own mental health difficulties, and secondly, how they felt about their therapist sharing this with them during therapy. A qualitative methodology was employed to capture such experiences. Participants provided rich accounts relating to their experiences of their therapist's disclosure, the impact on the therapeutic alliance and self, and specifically their views on therapists with mental health difficulties, including preexiting assumptions and how they conceptualised the identities of their therapist as both a professional and person.

This thesis consists of two chapters, a systematic review and an empirical paper, with additional information and supporting documents contained within the appendices. Both chapters are intended for publication in PLOS ONE and therefore written using the appropriate author guidelines (Appendix A) and the Vancouver style of referencing is therefore used throughout. The demand for mental health services in the UK continues to grow, as do the pressures on the NHS to continue to meet this demand, however, there is a compelling argument that psychological therapies should be one of many interventions that target the cumulative influences on mental health throughout the life course (1). It is recognised that advantage, or disadvantage starts before birth and accumulates through life, thus interventions at the earliest stage to reduce disadvantage, will generate the greatest subsequent benefits in improving physical and mental health and reducing inequalities (1,2). An aspect of our daily living, which has been associated with deleterious effects on mental health and wellbeing is our urban environment, evidenced by an increased likelihood of developing common and severe mental health disorders (3-5). While historically, significant gains have been made in relation to control of infectious diseases, with housing and sanitation improvements in our cities, mental health has not seen the same priority (6). Daily living conditions, including housing, have more recently been identified as important social determinants of mental health and included in recommendations for action (2). There is, therefore, a growing need for housing and urban environmental planning and design to be key aspects of public health intervention. Urban regeneration is one form of intervention used to provide area level improvement, often including improved housing. The impact of urban regeneration and housing interventions on health and mental health has been the subject of a number of systematic reviews (7-9). Existing reviews have demonstrated improvements to mental health in relation to targeted housing interventions, with inconsistent evidence for the impact of urban regeneration. One area that has been overlooked by earlier reviews is the impact of urban regeneration on the mental health of BME groups. Chapter 1 therefore aims to synthesise the quantitative evidence on the impact of urban regeneration on the mental health of BME groups. The findings from the systematic review demonstrated a significant lack of research in this area and highlights that inequality can only be targeted if all groups are included. Chapter 2 aims to explore psychological mechanisms thought to underpin the association between urban environments and mental health. The empirical paper demonstrated that briefly contemplating images of urban environments influences our consideration of future consequences, sense of personal control and attention to threat, thereby contributing to existing research concerning the urbanicity effect (3,10).

Exclusive breastfeeding (EBF) is evidenced to be the best preventative intervention for supporting child health outcomes worldwide (Global breastfeeding collective, 2017). The World Health Organisation (WHO) recommend six-months of EBF (WHO, 2011) to reduce infant mortality and protect against diseases for both mother and baby (Victora et al., 2016). Despite the known physical health outcomes, exclusive breastfeeding rates remain low; only 40% of infants were exclusively breastfed up to six-months worldwide (Global breastfeeding collective, 2017) and EBF rates in the UK were below one-per-cent (McAndrew, Thompson, Fellows, Large, Speed & Renfrew, 2012). It has been theorised that breastfeeding also has a positive association with the development of the bi-directional mother-infant relationship (Leung & Sauve, 2005; Scharfe, 2012). However, a review by Jansen, de Weerth and RiksenWalraven (2008) concluded that there was not sufficient evidence to support this link. The first paper within this thesis, a systematic review of the literature, aimed to extend the work of Jansen et al., (2008) by using a detailed search strategy and including the important concept of maternal sensitivity. This paper explores the relationship between breastfeeding duration and three aspects of the mother-infant relationship, namely infant-attachment, maternal-bond, and maternal sensitivity. Despite the many benefits of breastfeeding, many women experience breastfeeding difficulties, which have been named as a factor in breastfeeding cessation, and the experience of postnatal distress (Gerd, Bergman, Dahlgren, Roswall & Alm, 2012; Staehelin, Kurth, Schindler, Schmid & Stutz, 2013). Research has shown that women who initiated EBF before moving to formula feeding were at greater risk of experiencing guilt (Fallon, Komninou, Bennett, Halford & Harrold, 2017) and feelings of failure (Lee, 2007). However, the emotional impact of breastfeeding difficulties on women who continue to breastfeed is not known. The second paper within this thesis is a qualitative study which aimed to explore the experiences of eight women who had breastfeeding difficulties whilst continuing to breastfeed. This utilised Interpretative Phenomenological Analysis (IPA) to provide a detailed account of their experiences, and to understand the factors which enabled them to continue.

There is growing interest in the mental health of applied psychologists. Whilst the research pertaining to the mental health of trainee applied psychologists is emerging, there are few empirical studies in this area. The existing evidence base shows that training to become an applied psychologist is stressful (Cushway, 1992; Kumary & Baker, 2008) and mental health difficulties are prevalent in trainees (Grice, Alcock & Scior, 2018a). One way of reducing stress may be to access personal therapy (Bike, Norcross & Schatz, 2009). Disclosing mental health difficulties may also promote self-care and reduce stigma (Barnett, Baker, Elman and Schoener (2007). This thesis aims to explore and extend the research literature relating to trainee applied psychologists' personal development, wellbeing and mental health. The first paper addresses this through a systematic review of the impact of personal therapy on trainee counselling and clinical psychologists. This is followed by an empirical paper which explores factors that affect trainee clinical psychologists' decisions to disclose, or not disclose, their own mental health difficulties during their clinical psychology training. The systematic literature review was prepared for the Training and Education in Professional Psychology. A meta-synthesis approach was used to synthesise qualitative research into the impact of personal therapy for trainee clinical and counselling psychologists. Seven papers were included in the review. A total of eight themes and ten subthemes were identified. These are described along with a summary of the findings in the context of clinical and counselling psychology training and current research. Recommendations for practice and future research are made. The empirical paper was prepared for the Journal of Clinical Psychology. A grounded theory approach was used to understand what factors affect trainee clinical psychologists' decision to disclose, or not disclose, their own mental health difficulties during their clinical psychology training. This research aimed to build on the results of recent studies which have found high levels of mental health difficulties and low levels of mental health disclosure in trainee clinical psychologists. Twelve recently qualified clinical psychologists were interviewed about their experiences of mental health difficulties and disclosure decisions during their clinical psychology training. A theoretical framework was developed, which describes trainees' decision making processes relating to mental health disclosure. Participants' reasons for disclosing are described as well as the factors that inhibited disclosure and factors that enabled disclosure. The paper provides a detailed description of the methodology, analysis and findings. The implications of the research in terms of clinical psychology training are discussed and a number of recommendations are made for practice and further research.

Previous research has identified a relationship between early maladaptive schemas (EMS) and substance dependence, but there is a dearth of research investigating EMS and alcohol use in non-clinical populations, despite alcohol being the most commonly misused substance in the UK population. The aim of this study was to explore if EMS mediate the relationship between adult insecure romantic attachment (attachment anxiety and attachment avoidance) and alcohol use in a student population. A cross-sectional study of 128 student participants were recruited through the University of Liverpool intranet and by poster advertisement. Participants completed self-report measures comprising of: Alcohol Use Disorders Identification Test (AUDIT), Leeds Dependence Questionnaire (LDQ), Drinking Motive Questionnaire-Revised Short Form (DMQ-R SF), Experiences in Close Relationships –Revised (ECR-R) and Young Schema Questionnaire Short Form, Third Version (YSQ-S3). Bias-corrected bootstrapping indicated that the EMS domain ‘impaired limits’ mediated the relationship between adult insecure romantic attachment (both attachment anxiety and attachment avoidance) and alcohol use. Furthermore ‘impaired limits’ and drinking to cope with depression and anxiety were serial mediators in the relationship between attachment avoidance and alcohol use, but not for attachment anxiety and alcohol use. This research highlights the relationship between EMS and avoidant coping strategies (attachment avoidance and drinking to cope) on drinking behaviour.

The work contained in this thesis aims to explore the interplay between the online world and mental health, with a particular focus on identifying features of people's lives that confer vulnerability or resilience in the context of the online environment. Qualitative and quantitative methods were both used to establish the factors that confer vulnerability to specific problematic internet experiences, namely excessive social media use and cybervictimisation, or resilience to the negative outcomes of such experiences. In an attempt to better understand the psychology that underpins excessive social media use, attachment theory informed a quantitative study that aimed to illuminate why certain people use social media excessively (Chapter 3). Attachment anxiety was found to be positively associated with problematic social media use, whilst attachment avoidance was negatively associated with problematic social media use. Together, these findings suggest that attachment anxiety is a vulnerability factor and attachment avoidance is a protective factor in the context of social media overuse. The data further indicated that there was a significant indirect effect of attachment anxiety on problematic social media use via general feelings of well-being. In an attempt to develop a lifespan model of problematic social media use, the work focused on a psychological understanding of the link between childhood trauma, attachment insecurities, depressive symptoms, and problematic social media use in Chapter 4. Results revealed a history of childhood maltreatment was associated with more problematic social media use. Both insecure attachment dimensions (attachment anxiety and attachment avoidance) mediated the relationship between childhood maltreatment and problematic social media use in series with depressive symptoms. The model presented in Chapter 4 highlights novel environmental factors and psychological processes involved in the etiology of problematic social media use from a developmental perspective. In addition to illuminating the psychological factors that underpin excessive social media use, the work explored whether specific factors confer vulnerability to cyberbullying victimisation or protection against its negative effects in a sample of adolescents (Chapter 5). Victims of cyberbullying experienced higher levels of depression and anxiety and endorsed self-statements indicative of attachment anxiety more than non-victims. Positive coping styles, secure attachment, and higher levels of perceived social support from peers attenuated the positive relationship between cyberbullying victimisation and symptoms of depression and anxiety. In Chapter 6 qualitative methods are used to understand the psychological and interpersonal harms of being stalked via electronic means through the voices and experiences of 100 cyberstalking victims. Through a thematic analysis of their written reflections, this Chapter demonstrates that the emotional impact of cyberstalking predominantly includes comorbid depression and anxiety. The findings further reveal that the relationship between cyberstalking and mental distress is influenced by the prevailing resilience or vulnerabilities of the victims. Social support was found to be particularly helpful in the context of cyberstalking; however, when some victims sought help from significant others, it appeared to increase, rather than decrease, the negative impact of the cyberstalking ordeal. Adaptive coping styles such as the ability to cognitively reframe thoughts may enable the re-establishment of some emotional control and lay the course to a more resilient path; however, less adaptive coping styles appear to be a common response to cyberstalking victimisation. Overall, this body of research has contributed to our understanding of the relationship between the online world and mental health, and has identified risk and protective factors. The research presented here moves understanding forward by connecting up the increasing concerns of society regarding social media to the psychology that underpins them. The work further contributes to our understanding of the factors by which people's psychological adjustment is protected against the adverse effects of negative online experiences. In doing so, it supports well-being policy recommendations that should, in time, decrease the ill-effects of online lifestyles on future young people.

Background: This thesis examines savouring in people experiencing psychosis. Savouring involves the mental rehearsal of past, present and future positive experiences to intensify positive emotion (Bryant & Veroff, 2007; Addis, Wong & Schacter, 2007). The positive symptoms of psychosis, such as unusual perceptual experiences or beliefs, are often accompanied by negative symptoms that include reduced emotional expression and decreased motivated activity (Strauss, 2013). Attenuated positive and negative symptom traits, known as positive and negative schizotypy, are notable in the general population, and provide evidence that psychotic phenomena may exist on a continuum with ordinary human experiences, rather than separately within a 'discrete disease model' (Shevlin, McElroy, Bentall, Reininghaus & Murphy, 2017). People experiencing negative symptoms and those rating highly on measures of negative schizotypy report that they savour positive events in the past, present and future less often than unaffected control participants, and this relationship has been associated with reduced goal-directed activity (Applegate, El-Deredy & Bentall, 2009; 2014; Cassar, Applegate & Bentall, 2013). These groups may savour less due to cognitive difficulties, (Gard, Kring, Gard, Horan, & Green, 2007; Strauss, 2013) or because, according to social defeat theory, it may not feel socially safe to express positive emotion (White, Laithewaite & Gilbert, 2013). This thesis therefore aims to address three research questions; 1) what is currently known about savouring in psychosis; 2) could fear of positive emotion and lack of social safeness underpin reduced savouring; and 3) how could psychological interventions for negative symptoms be enhanced if the current findings are replicated in a clinical sample. Research rationale: Psychosis is estimated to affect 21 million people worldwide (World Health Organisation, WHO, 2018). A previous systematic review suggests that 15-20% of those experiencing psychosis will report negative symptoms (Buchanan, 2007). Thus, negative symptoms not only affect a vast number of people but they also represent a significant public health challenge, and a serious unmet health need for those who experience them because, as yet no fully effective treatment has been identified (Fusar-Poli et al., 2015). People experiencing psychosis, and their relatives, report that negative symptoms are particularly difficult to cope with, as changes to motivation, energy and functioning levels contrast starkly with prior capabilities (Rabinowitz, Berardo, Bugarski-Kirola & Marder, 2013; Mairs, 2017). Whilst positive symptoms might cause more noticeable changes in behaviour initially, it is the negative symptoms that often prevent participation in fulfilling activities such as employment, education and relationships (Snyder, Gur & Wasmer-Andrews, 2007). Negative symptoms are more strongly associated with poorer quality of life and lower social and occupational functioning than positive symptoms (Rabinowitz et al., 2012). Negative symptoms may be further exacerbated by extrapyramidal side effects, substance misuse, social withdrawal (due to increasing suspiciousness), and reactive low mood (Carpenter, Heinrichs & Wagman, 1988). A large scale, two-year follow-up study of people experiencing psychosis (N = 7678) found that identification of two or more negative symptoms at baseline was associated with increased likelihood of one or more readmissions, that lasted for an extended period of time (Patel et al, 2015). Whilst specialised psychosocial treatments for negative symptoms exist, and include cognitive-behavioural, activity-based and integrated interventions, (Mairs, 2017) all treatments have thus far proven to lack clinical effectiveness (Fusar-Poli et al., 2015). A meta-analysis of 34 randomised controlled trials (RCTs) of Cognitive Behaviour Therapy for psychosis (CBTp) found a small effect size of CBTp on negative symptoms (.21) and only two interventions were specifically designed to target negative symptoms (Wykes, Steel, Everitt, & Tarrier, 2008). A more recent meta-analysis of 168 RCTs testing a wide range of pharmacological and psychosocial interventions for negative symptoms, found that whilst some trials reported statistically significant effects on symptoms, no treatments translated into clinically meaningful outcomes, such as improved quality of life or functioning (Fusar-Poli et al., 2015). Therefore, better targeted, better evidenced and more clinically meaningful interventions are needed. The last major call for action to improve treatments for negative symptoms in the research community was led by the NIMH-MATRICS consensus group in 2006 (Kirkpatrick, Fenton, Carpenter & Marder, 2006). Thus it is necessary for renewed efforts to be made and it is hoped that this thesis will stimulate new research that enhances functioning, well-being and hope in people experiencing negative symptoms.

Introduction: A major focus of the field of global mental health in the last decades has been on bridging the treatment gap for priority mental health conditions in low and middle-income countries. Developmental disorders in children constitute one of the priority conditions and guidelines have been developed for their management within primary and secondary care in LMICs. However, a key obstacle in evaluating existing programmes and new interventions for development disorders, both from a research and service perspective, has been the lack of open access, reliable, and valid tools that can be used by lay-health workers or less experienced researchers to measure meaningful outcomes in such children. This PhD research, embedded within the scale-up of a communitybased intervention for developmental disorders in rural Pakistan, aimed to adapt and validate the World Health Organization's Disability Assessment Schedule for children (WHODAS-Child), a carer-administered functioning-related tool, in children with developmental disorders in these settings. Methods: The research was conducted in the rural sub-district of Gujar Khan in Rawalpindi, Pakistan. In Study 1, qualitative interviews, translation, back-translation and key informant consultations were conducted to inform the translation and adaption of the WHODAS-Child for children with developmental disorders (WHODAS-DD). In Study 2 (establishing validity and reliability of WHODAS-DD), 400 parents of children with developmental disorders and 400 parents of healthy children, all aged 2-12 years were administered the WHODAS-DD. A clinician rated score on the Developmental Disabilities Children's Global Assessment Scale (DD-CGAS) was used as the gold-standard. Factor analysis, validity, reliability and sensitivity to change analyses were conducted to evaluate the psychometric properties of the adapted measurement. Reliability was assessed in terms of internal consistency (Cronbach's alpha), inter-rater and test-rest reliability (intra class correlation). Confirmatory Factor Analysis (CFA) was conducted to establish factor structure of WHODAS-DD. Criterion, convergent and discriminative validity of WHODAS-DD was evaluated by applying correlation tests. Sensitivity to change was evaluated by change in disability scores, in terms of effect size, three months' post-intervention. Results: Study 1 showed that WHODAS-Child was transferable into a different setting and clinical population following a careful translation and adaptation process. The adaptation process did not require major changes to the structure of the tool, or introduction of new domains or items. Study 2 showed that the WHODAS-DD had good psychometric properties in children with development disorders in rural Pakistan, indicated by high internal consistency reliability (Cronbach's alpha, a: .82 to .94), test-retest reliability (ICC, .71-.98), and inter-rater reliability (ICC,.97-.99). The tool exhibited good criterion validity (r, -.71) convergent validity (r, -.35-.71), and divergent validity (r, 004) when compared with DD-CGAS. WHODAS-DD had the ability to discriminate among children with developmental disorders and healthy children [mean scores 52.00 (±21.97) vs 2.14 (±4.00); 95% CI, -52.05 to -47.67;] and adequate capacity to detect change over time (ES, .19-.23). Conclusions: The WHODAS-DD has the potential to be integrated into global child mental health programmes and could provide useful data on individual functioning for comparison across programmes, conditions, cultures and delivery systems. However, further studies are warranted to assess the psychometric properties of the tool in other settings, and to evaluate sensitivity to change over a longer period of follow-up.

This thesis provides an exploration into early interpersonal trauma, attachment styles, social functioning, reciprocal roles and procedures, dialogic and psychoanalytic processes associated with experiences of psychosis. Two papers encompass this thesis: (1) a systematic review examining the current literature on the relationship between adverse childhood experiences and social functioning of adults with experiences of psychosis, compared to those without adverse childhood experiences; and (2) an original qualitative study exploring cognitive analytic therapy (CAT) practitioners' reflections about their experiences of applying a preliminary model of CAT for psychosis (Kerr, Beard, Crowley, & Simpson, 2000) in practice and research contexts. This introductory chapter provides a brief overview of the two papers. Chapter 1: The systematic literature review explored the association between childhood adversity and social functioning of adults with clinical levels of psychosis, in comparison to clinical and non-clinical control groups without childhood adversity. Five databases (PubMed, Medline, PsycINFO, Scopus, and CINAHL Plus) were searched up to May 2018. Ten studies were identified, and each was appraised for methodological quality. Six of the studies showed significant negative associations between childhood adversity and premorbid social functioning (particularly during adolescence) within first-episode psychosis samples. Two of the studies showed no significant associations between sexual and/or physical abuse and current social functioning in chronic psychosis samples. The findings were discussed in relation to methodological limitations, and the clinical need to consider a history of interpersonal trauma and social functioning difficulties when working clinically with this population was emphasised. Chapter 2: The empirical study aimed to further develop and refine the preliminary model of CAT for psychosis (Kerr et al., 2000), from CAT practitioners' perspectives. A qualitative design using a constructivist approach to grounded theory methodology was chosen. Semi-structured interviews were completed with nine CAT practitioners working in secondary mental health services across the British Isles. A revised CAT-based model of psychosis emerged from analysis. A number of additional psychosocial processes were identified that could enrich the preliminary model, including individual and social context, insecure avoidant attachment styles, intolerable core emotions and internal dialogue, defence mechanisms, and specific maladaptive reciprocal roles associated with the development of delusional and hallucinatory experiences. These processes that underpin the final model were discussed in relation to existing research and theoretical developments in CAT, cognitive psychology, attachment, and neuroscience. Clinical implications, methodological critique, and suggestions for future research were also discussed.

Family caregivers may find themselves providing unpaid support to their family members with physical and/or mental health problems. This support can range from activities of daily living, such as personal care, to providing emotional and psychological support. There is some research exploring carers' experiences within the NHS in the UK but only one to date has focused specifically on carers of individuals with borderline personality disorder (BPD). Ninety-eight carers took part in a questionnaire-based study; 57 carers of individuals who meet the diagnostic criteria for BPD were compared to 41 carers of individuals with other mental health problems. The aim of the study was to investigate whether perceived stigma, perceived threat of strong emotions, and expressed emotion within the family environment predicted carer burden. The results showed that carers of those who met the diagnosis for BPD experienced higher levels of carer burden, stigma, expressed emotion (emotional over involvement and criticism) and perceived threat of strong emotions, compared to carers of individuals with other mental health difficulties. Emotional over involvement, criticism, carer group (BPD and mental health) and gender of participant were predictors of carer burden, with EOI explaining the most variance of burden. The authors conclude that a tailored intervention is needed for carers of individuals who meet the diagnostic criteria for BPD. The intervention should address interpersonal effectiveness, mentalisation and management of emotions. It is also suggested that future research should explore other potential predictors of carer burden including household income, social support and quality of life.

Burnout has been associated with negative outcomes for both mental health service staff and service-users. However, despite being a well-established phenomenon, the literature surrounding burnout in mental health services is somewhat limited compared to the extensive attention burnout has received in other fields. Morse, Salyers, Rollins, MonroeDeVita, and Pfahler (2012) reflect the irony that the mental health field has focused little attention to its own workers. Indeed, there has been a call to "redouble efforts within this sector of healthcare to better understand and address the high levels of distress among those providing mental health services" (Paris & Hodge, 2010:526). By increasing the understanding of the prevalence, cause, and effect of burnout within mental health services, it is hoped to better inform possible interventions to reduce distress. It is notable the British Psychological Society (BPS) and New Savoy Partnership have brought to the fore the importance of psychological wellbeing of the psychological therapy workforce. The joint 'Charter for Psychological Staff Wellbeing and Resilience', appeals for: greater support of staff wellbeing, requiring clinical leaders who value the dedication of staff and support staff wellbeing (BPS, 2016). The role of the clinical psychologist has expanded beyond individual client work. Clinical psychology competencies (BPS, 2006) specifically identify the use of broad-based knowledge to: assess, formulate and intervene, both with individuals and within service systems. Furthermore, the HCPC Standards of Proficiency (2015) outline the role of psychologists in intervening psychologically in service systems. Thus the impetus to bring psychological skills and knowledge to service systems is unambiguous. Within the NHS, team-working is central to the role of clinical psychologists and is reflected in the New Ways of Working: Working Psychologically in Teams (BPS, 2007). This guidance specifically identifies leadership and team-working roles for clinical psychologists. Furthermore, it highlights that local team development interventions and process should include how teams will remain healthy and functioning. It is argued that systems and organisational interventions must augment individually focused interventions to address burnout (Paris & Hodge, 2010; Public Health England, 2016). Arguably, clinical psychologists have the skills and competencies to meet both of these challenges when working within teams in mental health services. The two papers within this thesis attempt to address the supposition by Paris and Hodge (2010) and Public Health England (2016) that further research exploring staff burnout in mental health services is required and that this should focus on both systemic and individual factors. The first of the chapters aimed to address the potential benefit of Acceptance and Commitment Therapy (ACT) as an individually-focused intervention for burnout; while the second chapter presents a study which aimed to address developing a better understanding of the systemic level factors that contribute to burnout and the potential effects of burnout on service-users.

This thesis examines the relationship between shame and the psychosis continuum and proceeds with a specific focus on hearing voices. Two chapters are presented. Chapter one consists of a systematic review of the literature examining the nature of the relationship between shame and the psychosis continuum. Chapter two is an empirical paper exploring whether experiences of social deprivation and shame are associated with the beliefs that individuals hold about their voices or the relationships that they have with them. This introductory chapter provides a brief overview of the constructs examined and the ethical standpoint of the research. The term psychosis is used to describe disturbances in thinking, perception, mood, and behaviour (e.g., delusions, hallucinations, incoherent speech; Cooke, 2014; National Institute for Health and Care Excellence, 2014) that are often associated with a range of social adversities (Longden & Read, 2016). In England, the annual prevalence of psychotic disorder is four individuals per 1000. The pooled annual incidence, that is the number of individuals developing the disorder for the first time in one year, is 32 cases per 100,000, with incidence being higher in men prior to the age of 45 years and becoming increasingly equal thereafter (Kirkbride et al., 2012). Many individuals with psychotic experiences are often diagnosed with schizophrenia spectrum disorders with the use of diagnostic systems such as the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2013). This is despite growing criticism regarding the reliability and construct validity of these systems, their failure to account for the impact of a range of social adversities and their limited ability to predict real-life outcomes (Read, 2013; Read, Bentall, & Fosse, 2009). There is growing evidence that psychotic experiences occur on a continuum in the general population (van Os, Hanssen, Bijl, & Ravelli, 2000) with clinical psychoses representing the upper or more extreme end of the continuum (Shevlin, McElroy, Bentall, Reininghaus, & Murphy, 2017). 'Hearing voices' is a term that is utilised by many including the Hearing Voices Network (HVN, 2013) to describe what is frequently referred to in the literature as auditory verbal hallucinations–sensory perceptions with a compelling sense of reality that occur without external stimulation (APA, 2007). Hearing voices is a common experience (Johns et al., 2014) that is often, yet not always, associated with distress (Birchwood, Meaden, Trower, Gilbert, & Plaistow, 2000). Research has identified associations between the relationships and beliefs that an individual has about their voices and the level of distress experienced (Birchwood & Chadwick, 1997). Findings have also identified a mirroring of the relational dynamic between the voice-hearer and their voices and others in their external environment (Birchwood et al., 2004). The importance of negative emotions including shame is increasingly being recognised in relation to the development and maintainence of psychotic experiences (e.g., Birchwood, Iqbal, Chadwick, & Trower, 2000; Birchwood et al., 2004; Birchwood, Trower, Brunet, Gilbert, Iqbal, & Jackson, 2006; Freeman & Garety, 2003; Gumley, 2007). Shame is a negative emotion that involves intense feelings of inferiority and defectiveness and the desire to escape and hide (Tangney, 1995). It is an internal subjective emotion that involves evaluation of the self in relation to others (Gilbert, 1997; 1998) and therefore could be seen to be relevant to voicehearing where mirroring of the relationship between the voice-hearer and their voice(s) and external others has been identified. Therapies that target shame such as compassion-focused therapy are being increasingly utilised in individuals experiencing or recovering from psychosis (Braehler, Gumley, Harper, Wallace, Norrie, & Gilbert, 2013; Gumley, Braehler, Laithwaite, MacBeth, & Gilbert, 2010). The HVN is an international network of individuals with lived experience of voice-hearing who conceptualise voice-hearing as a meaningful response to difficult life experiences. They describe the importance of understanding the content and meaning of voice-hearing experiences and of accepting individual interpretations or explanations (HVN, 2013). The ethos of the HVN is adopted as one of the primary frameworks for the current study. This framework–of viewing voice-hearing experiences as meaningful responses to difficult life events–is also utilised in chapter one when examining other experiences of psychosis. Despite reference to literature that uses diagnostic language, the current research aims to be transdiagnostic and to investigate associations between specific internal and external markers of status and specific psychotic experiences. Within this research it is also acknowledged that for some individuals' psychotic or more specifically voice-hearing experiences may not be distressing and that in fact they may be perceived to be valuable.

The study of Executive function (EF) in early child development is not fully established, with much still to be confirmed regarding its latent structure and early precursors. Proposed mechanisms underlying reported inverse associations between prenatal stress (PNS) and general cognitive development suggest that brain regions associated with early EF may be specifically vulnerable, yet this is a largely unstudied area. Postnatal caregiving may modify PNS effects on EF providing a possible early intervention target to improve developmental outcomes. This thesis comprises three linked studies. Study 1 examined latent EF structure in toddlers. Study 2 investigated associations between different forms of PNS in each trimester of pregnancy and toddler EF, and tested whether they were sex-dependent. Study 3 tested the moderating influence of early maternal caregiving on associations observed in study 2. Methods: This research was embedded within the prospective longitudinal Wirral Child Health and Development Study. Study 1: 254 toddlers (mean age 31.4m) completed a battery of EF tasks. Study 2: Mothers reported anxiety symptoms (STAI) at 20 weeks’ and 32 weeks’ gestation, and number of stressful life events (SLEs) via an investigator-led interview for each pregnancy trimester and at multiple postnatal timepoints. Toddler latent EF abilities derived in study 1 were the cognitive outcome. Study 3: Mothers reported frequency of stroking their baby at 4 and 9-12 weeks old, yielding a tactile stimulation index of early caregiving. At 6 months, maternal sensitivity was observed and rated during free play. Results: Study 1: CFA applied to EF data yielded 2 distinguishable yet moderately correlated (r = .43) factors:- working memory (WM) and inhibitory control (IC). Study 2: Multiple linear regression models revealed that 32-week STAI scores in interaction with sex predicted toddler WM (β =0 .55; p < .05), accounting for 2% of the variance in scores after accounting for pre and postnatal confounders; and 1st trimester SLEs in interaction with sex predicted IC (β = 0.45; p = .05), accounting for 2% in outcome. Both interactions arose from a similar pattern of opposite associations between PNS and EF in males and females. Study 3: PNS effects were not moderated by maternal tactile stimulation. The prediction of toddler IC by the 1st trimester SLE by sex interaction was moderated by maternal sensitivity. This 3-way interaction accounted for 3% of variance after accounting for confounders. Conclusions: EF exhibits an integrative latent structure in toddlerhood; PNS was associated with poorer EF in males and relatively enhanced EF in females; exposure to higher maternal sensitivity in the first months of life eliminated the observed sex-dependent PNS effects on toddler IC but not WM. Findings are discussed in the context of Developmental Origins of Health and Disease model and evolutionary perspectives on sex-dependent development.

Background: In most circumstances we easily distinguish changes to the external world brought about by our own actions from those with external origins. However, there are contexts where the sense of agency is put into question. Little is known about ambiguity characterised by a lack of information for self-other differentiation, despite its relevance to symptoms and levels of consciousness associated with certain mental health conditions. In this PhD thesis by publication, behavioural and neuroimaging methods are used to explore self-other processing capacities in ambiguous conditions. Individual differences are examined in relation to brain response with the aim of shedding light and generating further testable hypotheses on mechanisms of agency in both health and psychosis. Chapter 2: Building on ideas from developmental and perceptual psychology, Chapter 2 lays out the theoretical framework and rationale behind the experimental work. The paper defines the concept of ambiguity in relation to self-other processing. With caregiver-infant interactions and social interactions more generally described as inherently ambiguous, a key proposal is that experience in ambiguity-promoting settings provide conditions necessary for developing reality-testing abilities and a flexible sense of self-other associated with mental heath. Such abilities may be malleable, however, continuing to develop through experience in activities involving intricate joint action such as social dialogue. It is argued that activities such as music-making which require self-other distinctions, yet make differentiation challenging may particularly hone these skills. Implications for phenomena such as hallucinations associated with reduced attributional abilities are discussed. Chapter 3: In the first experimental study, a task was developed that manipulates ambiguity by controlling the probability that a participant’s finger taps results in auditory tones as opposed to tones generated by ‘another’s finger taps’. The ability to accurately attribute actions to self and to other was negatively related to hallucination proneness (HP) and positively related to musical experience (ME). This pattern of results was accentuated by ambiguous conditions where the probability of self- and other-generated tones was equal. This not only associates HP with specific difficulties in dealing with ambiguity, but also supports the notion that attribution abilities are malleable and can improve through experience in ambiguous settings such as those involving intricate joint action. Chapter 4: Chapter 4 investigated neural responses to modulating the degree of control belonging to self and other using the probability method tested in Chapter 3 in a parametric fMRI block design. Linear and non-linear stimulus-response functions highlighted a network of brain regions previously associated with motor control and self-other processing to be particularly sensitive to control belonging to self. All regions also displayed significant non-linearity with decreased response in ambiguous conditions. This study provides initial insight into attributional ambiguity-processing in the brain. Chapter 5: In Chapter 5, neural responses to the task were examined in relation to individual differences. Combining whole-brain univariate and a task-based ICA approach, results showed increased ambiguity-related response in sensory and DMN regions to be related to positive schizotypy and difficulties in processing ambiguity, in contrast to task performance and musical experience which correlated with reduced response. Chapter 6: The final study examined the effects of attribution performance, including performance specifically related to ambiguity, on resting-state functional connectivity using ICA, dual regression and a network analysis. Findings showed connectivity between frontal networks and other brain regions increased with reduced task performance. Conclusions: The thesis concludes with a discussion of these collective findings and implications for future research. Together the behavioural and imaging findings point towards the importance of ambiguity in self-other processing. Increased insight into the topic may enhance our understanding of agency mechanisms underlying ‘self-disorders’ such as schizophrenia and eventually contribute to extending the range of therapeutic possibilities.

Every year in the UK and Wales, 3,750 children (aged 15 years or under) are seen in accident and emergency departments following a burn injury (Child Accident Prevention Trust [CAPT], 2012). Around 95% of injuries occur at home and are predominantly the result of everyday situations, such as a scald from a hot drink or contact with electrical appliances (CAPT, 2012). Burn injuries can involve long-lasting painful and physical consequences for the child (e.g. skin grafts, rehabilitation and permanent scarring). However, the psychological impact of an injury is not limited to the child affected. Indeed, parents are often more emotionally distressed than the children themselves (Kent, King, & Cochrane, 2000). This thesis will focus on the psychological adjustment of parents following their child's burn injury. Previous research has indicated that parents experience elevated levels of distress. For instance, 50% of parents whose child required an inpatient admission met clinical criteria for traumatic stress (Bakker, Van der Heijden, Van Son, & Van Loey, 2013). High rates of depression and anxiety have also been reported (Phillips & Rumsey, 2008). In addition, parent's post-burn adjustment has direct implications for their child's emotion and physical recovery (De Young, Hendrikz, Kenardy, Cobham, & Kimble, 2014). Research can therefore play an important role in identifying factors that are associated with this adjustment process. Such findings could inform clinical practices, for instance, in providing better identification and support of families who may be struggling. To this end, the thesis will examine what puts families at risk of poor adjustment and what protects against this. The thesis takes the form of two chapters: a systematic review and an empirical paper. In the systematic review, a search of the literature was undertaken to identify all factors associated with adjustment. Poor adjustment was operationalised as the experience of symptoms of depression, anxiety and post-traumatic stress disorder. The findings were synthesised using a narrative approach. Overall it was found that objective injury characteristics (e.g. burn size) were poor predictors for parent's adjustment. Instead subjective appraisals of the burn event, parent's pre-existing difficulties, the child's symptoms of PTSD and systemic factors were all robustly associated with parents' distress. The empirical paper investigated the impact of subjective factors: guilt and shame and self-compassion on parental adjustment. The study expanded previous findings that guilt is a common experience among parents of children who have sustained a burn injury (Mason, 1993). For example, it used a validated measure of guilt to examine this complex emotion and is the first to consider the related construct of shame. A sample of parents was recruited at a regional children's burn unit (Alder Hey Children's Hospital, Liverpool) during the acute phase following their child's burn injury. Guilt, shame and self-compassion were found to be good predictors for adjustment in parents, while objective characteristics of the burn injury were less important. Furthermore this study contributed to the growing body of evidence that guilt and shame represent distinct constructs and are differentially associated with psychological outcomes (Kim, Thibodeau, & Jorgensen, 2011). Overall these two papers integrate and extend our current understanding of parental adjustment in the context of paediatric burn injuries. Both papers offer a number of clinical recommendations which may help to improve patient care.

This thesis focuses on the relationship between young people who affiliate with alternative subcultures and self-harm and/or suicide. Alternative subcultures can be described as groups that are distinct from 'mainstream' cultures. Affiliation with such groups can be broadly defined as having a strong collective identity to a group with specific values and tastes, typically centred around music preference, clothing, hairstyles, make-up, tattoos and piercings (Greater Manchester Police; GMP, 2013; Moore, 2005). Some alternative subcultures have also been associated with 'dark, sinister and morbid' themes, such as Goths, Emos, and Metallers (Young, Sproeber, Groschwitz, Preiss, & Plener, 2014). Self-harm can be defined as the deliberate act of harming oneself, with or without suicidal intent. This commonly involves cutting and self-poisoning (NICE, 2013). Other behaviours that can be described using this term include non-suicidal self-injury (NSSI; the intentional destruction of body tissue without suicidal intent) and suicidal behaviours such as suicidal ideation and attempts (self-harm with some intent to die; Klonsky & Muehlenkamp, 2007; Nock, Borges, Bromet, Cha, Kessler, & Lee, 2008). Some would argue that NSSI is distinct from self-harm, and as such it features as a disorder in the DSM-V as Non-Suicidal Self-Injury Disorder (NSSID; APA, 2013), however there remains some controversy over the latter (Kapur, Cooper, O'Connor, & Hawton, 2013). The associations between alternative subgroup affiliation and self-harm and/or suicide were explored through a systematic review and empirical research study using quantitative methodology. It is well documented in the literature that the prevalence of self-harm and suicide is particularly high in adolescents and young adults, with suicide being one of the leading causes of death in this population (Hawton, Saunders, & O'Connor, 2012; WHO, 2014). Self-harm has become a clinical and public health concern with up to 30,000 adolescents receiving hospital treatment each year (Hawton, Rodham, & Evans, 2006) and prevalence rates rising to between 7-14% for young people in the UK (Hawton & James, 2005; Skegg, 2005; Swannell, Martin, Page, Hasking, & St John, 2014). Minority groups are another population who appear to have elevated rates of self-harm, including Lesbian Gay Bisexual and Transgender (LGBT; Jackman, Honig, & Bockting, 2016), ethnic minorities (Bhui, McKnezie, & Rasul, 2007) and alternative subcultures (Young et al., 2014). However, there is a paucity of research into the latter population. This presented a gap to conduct a systematic review of the available literature in an attempt to understand the association between alternative subculture affiliation and self-harm and suicide. Chapter 1 describes the systematic process taken in an attempt to understand the links between alternative subculture affiliation and both self-harm and suicide. Ten studies were included which focused on self-harm and/or suicide and alternative identity through subculture affiliation (e.g. Goth) or music preference (e.g. Heavy Metal). The results indicated that there is an association between alternative subculture affiliation and self-harm and suicide, though the lack of research in the area and methodological limitations impact on the extent to which the underlying mechanisms can be understood. Leading on from the systematic review, Chapter 2 presents the empirical study which investigated the factors that might contribute to the increased risk of NSSI in alternative subcultures, specifically focusing on variables that have been found to be linked to NSSI in young people; emotion dysregulation, depression, identity confusion and exposure to self-harm. The aim of this study was to increase our understanding of the mechanisms involved that might explain this increased risk of NSSI. Alternative subcultures were found to be at a greater risk of NSSI in comparison to affiliations with other subcultures, though this association lessened when the other variables were accounted for. A key predictor of NSSI in this population was emotion dysregulation. The findings highlight the importance of raising awareness of the potential risk of self-harm/suicide in alternative subcultures in order to create a greater understanding and direct resources appropriately.

Empirical evidence indicates that clinical trials are the most challenging type of research where the recruitment of willing volunteers is required. Insights into the process of recruitment are being gained from research examining the perspectives of those individuals directly involved, but there is limited comparative work in this area. Cystic fibrosis (CF), a serious life-long health condition was chosen as a case study for this thesis. It enabled recruitment to be compared across both adult and child settings and from both sides of the exchange. Qualitative interviews were conducted with 82 informants, comprising 20 adult patients, 22 mothers, eight fathers, 12 young people and 20 practitioners, across ten specialist CF centres (five paediatric and five adult). Analysis of transcribed recordings was pluralistic, drawing on elements of grounded theory and discourse analysis. Findings from this case study indicated that informants were able to make sense of invitations to participate in clinical trials based on personal perceptions of fairness, which could be discerned according to three distinct yet interdependent discourses namely: a rational; a social and a psycho-moral discourse. Rather than a universal ethical principle of fairness, informants made their own judgements of fairness, which took different forms depending on their personal sense of responsibility. Parents acting on behalf of infants and young children focused on doing the right thing and acting in the child's best interest, balancing both parental responsibilities and personal values. Parents of older children focused on negotiating the young person's level of involvement in decisions according to pre-existing family dynamics. Adult patients balanced their own health status, past research experience and personal values to make sense of and respond to the invitation to enter a trial. Practitioners illustrated the delicate balance required for the 'unbiased marketing' of trials, in which they considered their duty of care to patients, inherent trial uncertainty, 'a pressure of numbers' and their own personal values. In the context of this lifelong condition, recruitment was a social exchange as well as an informational one, in which hope, trust and a sense of moral responsibility were central for informants. Vulnerabilities could arise in relation to these processes, where high hopes could lead to disappointment, a sense of responsibility could lead to obligation, or trust could turn to acquiescence. The findings have implications for enhancing recruitment and raise questions about the appropriateness of generic checklist guidelines for enhancing and supporting the recruitment process. Individuals and families approached about trials want to be part of something of value and to be valued; engaging in what they believe is a worthwhile and fair collaborative endeavour.

Pregnancy is a time of physiological and psychosocial change for women, and can be a stressful life event (Hodgkinson, Smith & Wittkowski, 2014). Therefore, for some women, pregnancy can exacerbate existing psychological distress (e.g. depression, anxiety and/or stress), or contribute to its development (Biaggi, Conroy, Pawlby & Pariante, 2016). Although there are many reasons why some women experience psychological distress during pregnancy (e.g. lack of social support; Biaggi et al., 2016), this thesis is concerned with the impact of foetal congenital anomaly diagnosis on maternal mental health. Specifically, congenital heart disease (CHD) and cleft lip and/or palate (CL/P). The original focus of the thesis was planned to be exclusively on prenatal CL/P diagnosis, however it was deemed unfeasible to conduct a systematic review in this area due to a lack of relevant quantitative research. CHD was therefore chosen as it is a commonly diagnosed congenital anomaly with sufficient literature available to conduct a systematic review. Chapter one of this thesis therefore aims to critically review, and synthesise the available literature to gain an understanding of whether prenatal CHD diagnosis is associated with maternal mental health difficulties. Clinical implications and directions for future research are considered. The empirical paper presented in chapter two of this thesis focusses on the impact of prenatal CL/P diagnosis on maternal mental health and its associations with antenatal attachment (AA), mindfulness and self-compassion (SC). AA was selected as a variable of interest due to associations between psychological distress in pregnancy and reduced maternal-foetal attachment (Alhusen, 2008; Rubertsson, Pallant, Sydsjo, Haines & Hildingsson, 2015). Furthermore, identifying factors that might contribute to the promotion of increased AA and optimal mental health in pregnancy is therefore important. Mindfulness and SC are two such factors which are increasingly demonstrating their efficacy as concepts related to reducing psychological distress and enhancing AA in pregnant women (Dunn, Hanich, Roberts & Powrie, 2012; Matvienko-Silkar, Lee, Murphy & Murphy, 2016; Mohamadirizi & Kordi, 2016). The empirical paper provides an overview of relevant research, a description of the methods used to address the research question, followed by a discussion of the results. Implications for antenatal services and directions for future research are provided.

Chapter One is a systematic review that aims to investigate the relationship between glycaemic control and quality of life (QoL) in adults with Type 1 Insulin-Dependent Diabetes Mellitus (IDDM). The National Institute for Health and Care Excellence (NICE, 2015) proposes that adults with IDDM should aim to achieve a near-normal glycaemic range, as indicated by the measurement of glycated haemoglobin (HbA1c), to reduce the risk of severe life-changing complications. Anecdotally, in clinical practice, it is assumed that those who achieve good glycaemic control and meet the required HbA1c target also have good QoL; however, striving for a near normal HbA1c, and the associated treatment burden, may have a negative impact upon QoL. The negative impact of treatment burden on QoL may be a necessary compromise, as achieving a near normal HbA1c is likely to safeguard the person from IDDM- related complications in the long-term, which will inevitably impact upon QoL later (Rubin & Peyrot, 1999). Therefore, it is not yet established how achieving a near-normal HbA1c impacts upon QoL. These issues were brought to life clinically, as the lead researcher spent time in the Paediatric Diabetes Department, and this fuelled their interest in investigating the relationship between HbA1c and QoL in adults with IDDM. Seven studies are included in the review. Few studies set out to investigate the relationship between HbA1c and QoL. The overall quality of the research is poor. Three of the seven studies indicated that there was no relationship between HbA1c and QoL, one study identified a negative correlation, one study offered mixed results, and two studies proposed that a curve-linear relationship best described their data. Therefore, the review is unable to provide a conclusive statement regarding the nature of the relationship between HbA1c and QoL. The review does not support the commonly held anecdotal assumption that good glycaemic control, as indicated by HbA1c, equates to good QoL. Furthermore, the review highlights the limitations of quantitative research design and methodology when investigating a subjective and dynamic phenomenon such as QoL. The limitations found in the quantitative studies included in the systematic review informed the design of the empirical investigation that employs qualitative methods. Chapter Two is an empirical paper that describes a qualitative study that explored how adolescents aged 13 to 19 with IDDM experience themselves as able to 'live well' despite their chronic condition. IDDM is one of the most common childhood conditions in the UK, and it requires careful management to reduce the risk of life limiting and life changing complications (Spencer, Cooper & Milton, 2010). As with adults, UK healthcare policy proposes that young people aim to achieve near normal glycaemic control to reduce the risk of IDDM complications (NICE, 2015). Adolescents with IDDM typically have poor glycaemic control and this poses a significant challenge to diabetes healthcare teams (Burke & Dowling, 2007). The extant literature explores 'barriers' to control and focuses upon the negative impact of IDDM; it is 'problem saturated' (Balfe et al., 2013). The purpose of this paper was to explore qualitatively how some young people are able to experience themselves as living well in adolescence despite IDDM. In contrast to the systematic review of quantitative research regarding HbA1c and QoL in adults, this paper uses a qualitative design that specifically explores the experiences of adolescents; a population who generally have poor control. Furthermore, it is hoped that this positive psychological approach will address a gap in the literature and may help deepen the understanding of the psychological and social processes that enable some young people to live well with a chronic condition. The lead researcher has a longstanding interest in working with adolescents.a subjective and dynamic phenomenon such as QoL. The limitations found in the quantitative studies included in the systematic review informed the design of the empirical investigation that employs qualitative methods. Chapter Two is an empirical paper that describes a qualitative study that explored how adolescents aged 13 to 19 with IDDM experience themselves as able to 'live well' despite their chronic condition. IDDM is one of the most common childhood conditions in the UK, and it requires careful management to reduce the risk of life limiting and life changing complications (Spencer, Cooper & Milton, 2010). As with adults, UK healthcare policy proposes that young people aim to achieve near normal glycaemic control to reduce the risk of IDDM complications (NICE, 2015). Adolescents with IDDM typically have poor glycaemic control and this poses a significant challenge to diabetes healthcare teams (Burke & Dowling, 2007). The extant literature explores 'barriers' to control and focuses upon the negative impact of IDDM; it is 'problem saturated' (Balfe et al., 2013). The purpose of this paper was to explore qualitatively how some young people are able to experience themselves as living well in adolescence despite IDDM. In contrast to the systematic review of quantitative research regarding HbA1c and QoL in adults, this paper uses a qualitative design that specifically explores the experiences of adolescents; a population who generally have poor control. Furthermore, it is hoped that this positive psychological approach will address a gap in the literature and may help deepen the understanding of the psychological and social processes that enable some young people to live well with a chronic condition. The lead researcher has a longstanding interest in working with adolescents.

Chapter One is a systematic review which aims to investigate existing research into the relationships between socio-economic status (SES), psychological distress and maladaptive eating behaviours. To date, no systematic review has been published which examines the available literature on the inter-relationships between these variables. This area was chosen for review due to a recent theoretic model by Hemmingsson (2014), which proposes a socio-emotional model of obesity encompassing these variables. Eleven papers were found to meet criteria for the review. Chapter Two is an empirical paper which aimed to explore the role of psychological and emotional factors in the relationship between SES and BMI. Lower SES has been shown to be significantly associated with higher body weight (Parsons, Power, Logan, & Summerbelt,1999). There is currently little understanding as to the psychological mechanisms which underpin this relationship (Stamatakis, Primatesta, Chinn, Rona, & Falascheti, 2005). The majority of available research has considered non-psychological factors such as availability of low-cost food, however, findings of such research have not been able to fully account for the relationship between SES and obesity (Cobb et al., 2015). The aim of the empirical paper was to investigate predictions based on the theoretical socio-emotional model of obesity proposed by Hemmingsson (2014). Primarily, the study considers whether socio-economic disadvantage increases psychological distress which, in turn, promotes maladaptive coping behaviours, such as emotional eating, and ultimately obesity. Furthermore, the study assesses if resilience moderates the association between socio-economic disadvantage and distress, thus providing a protective role. The empirical paper will be submitted to the British Journal of Health Psychology for publication. This journal was chosen by the author due to its interest in publishing original research into psychological aspects of health and health-related behaviours. As a result, it was felt that the empirical paper was appropriate for the journal in question and satisfied its remit and objectives.

Objective: Obstetric interventions during labour and birth can be a risk factor for experiencing birth negatively, and experiencing postpartum psychological distress. Perineal trauma is the most frequent obstetric complication to occur during childbirth, yet its effects on wellbeing are relatively unexplored. This research aimed to explore women's experiences of different degrees of perineal trauma sustained during childbirth. Methods: The 'PEACH' study (Psychological health and relationships Experiences After vaginal CHildbirth) was a mixed-methods study that used questionnaires at 48 hours, 6-12 weeks and 6-10 months after a first vaginal childbirth, to assess experience of birth and symptoms of psychological distress. Women were classified into three groups according to the perineal trauma experienced i.e. a 1st/2nd degree tear, an episiotomy or an Obstetric Anal Sphincter Injury (OASI). A sub-sample of women who experienced OASI were interviewed about their experiences between 6-10 months after they had given birth. Findings: Women with OASI and those who experienced an episiotomy were more likely to report their birth as a traumatic event, and report a more negative experience of birth than those with a 1st/2nd degree tear. Those who experienced an episiotomy experienced a more negative perceived body image at 6-12 weeks and more anxiety symptoms at 6-10 months postpartum. A clear variation in women's responses to OASI was observed in their interviews, whereby some women were distressed by their experiences and others were not so distressed. Key conclusions: Experiencing psychological distress after OASI is not as inevitable as previously thought. Adequate care/support of women who experience perineal trauma may increase psychological resilience and facilitate adaptation to the challenges experiencing perineal trauma may propose. Women's experiences of episiotomy may be underestimated and further research is required to establish the care needs of women with episiotomies and other degrees of perineal trauma.

Callous-unemotional (CU) traits have proved to be a robust and informative construct; identifying a subgroup of children with conduct problems who show more severe and persistent antisocial behaviour. The majority of this work has focused on mid to late childhood and adolescent samples, yet the study of CU traits in early childhood allows identification of developmental pathways to CU traits and may inform the development of preventative interventions. The three empirical studies included in this doctoral thesis use a longitudinal epidemiological sample (Wirral Child Health and Development Study; WCHADS) followed from pregnancy up to age 7 years to examine important questions regarding: 1) the measurement of CU traits in early childhood 2) the contribution of the early parenting relationship to child CU traits; specifically maternal sensitivity to infant distress, with possible mediation by child attachment status, and 3) a candidate sex dependant mechanism for the translation of CU traits into physical aggressive from early to mid-childhood. The first study uses the extensive sample of consecutively recruited first time mothers and the second two studies focus on a subsample stratified by psychosocial risk. The aim of the first study (Chapter 2; n = 775) was to adapt a CU traits measure for use with preschool children. The CU measure derived showed acceptable psychometric properties, factorial invariance by sex and good stability to 5 years. Validity was supported by cross-sectional associations with physical aggression for both boys and girls and incremental prediction to aggression at age 5 in girls only. The second study (Chapter 3; n = 272) examined the longitudinal contribution of maternal parenting behaviours (sensitivity to distress and to non-distress, positive regard, intrusiveness) at 7 months and attachment status at 14 months to child CU traits assessed from age 2.5 to 5 years. Latent variable modelling yielded a single parenting factor which, in line with predictions, significantly predicted reduced CU traits. The effect was mainly explained by sensitivity to infant distress and positive regard towards the infant. These two indicators evidenced a significant interaction, such that the combination of low positive regard and low sensitivity to distress predicted increased child CU traits. Neither attachment security nor disorganization predicted CU traits, so there was no evidence for mediation by attachment status. The final study (Chapter 4; n = 276) examined a hypothesised sex-specific mechanism for the translation of CU traits to aggression via HPA –axis reactivity to stress. Age 5 cortisol reactivity was found to significantly moderate the association between age 5 CU traits and age 7 teacher and mother reported aggression, evidenced by a significant 3-way interaction with sex. There was a significant two-way interaction in boys, such that higher CU traits and lower cortisol reactivity predicted increased physical aggression. Overall, this thesis provides support for the valid measurement of CU traits over the early preschool period. Sensitivity to infant distress, alongside positive regard/warmth, predicted reduced CU traits suggesting that early interventions might also focus on enhancing maternal responsiveness to distress. Findings supported the role of cortisol reactivity to social stress in the translation of CU traits to aggression and critically this was sex specific.

Attention Deficit Hyperactivity Disorder (ADHD) is the most common childhood mental health diagnosis, with estimates of prevalence continually increasing. However very little research has explored young people's experiences of their diagnosis and treatment, despite adolescence being a critical period for development. This thesis synthesises and extends the existing qualitative research undertaken with adolescents diagnosed with ADHD regarding their life experiences following diagnosis. It particularly focuses upon the impact of 'being diagnosed with' and 'medicated for' ADHD. Two papers comprise this thesis: a systematic literature review and an original research paper, which are briefly described below. The systematic literature review was prepared for submission to Emotional and Behavioural Difficulties. It utilised systematic search strategies and conducted a thematic synthesis to identify and synthesise the existing qualitative literature on the experiences of adolescents diagnosed with ADHD. Eleven papers were eligible for inclusion in the review and each was appraised for methodological quality. Five analytical themes were identified: Differing perspectives of the problem; Societal pressures; Sense of self; Feelings about medication; and Maturational shift from passive to active. The findings are discussed in terms of culture and identity, and the need to highlight strengths and autonomy is emphasised. The empirical paper was prepared for submission to Clinical Child Psychology and Psychiatry. It used a grounded theory approach with eleven adolescent participants (aged 16-18 years old) who had been diagnosed when they were aged between 8 and 13 years old. This paper focused on young people's identity development and how this was impacted by their diagnosis and treatment. A comprehensive theoretical model of the findings was constructed, which visually depicted participants' transitions through seven distinct stages, which each had profound implications for their identity. These findings were discussed in relation to the factors involved in the development of a healthy identity, and the value of diagnosis and treatment was critically considered.

Both posttraumatic growth (PTG) and posttraumatic stress disorder (PTSD) are associated with spirituality and different kinds of repetitive thinking, such as deliberate rumination (DR) and intrusive rumination (IR) respectively. This study aimed to examine if spirituality modifies the relationship between types of rumination and trauma outcomes. Method: Ninety-six students from the University of Liverpool completed an online survey of four questionnaires: The Posttraumatic stress Diagnostic Scale, the Event Related Rumination Inventory, the Posttraumatic Growth Inventory-Short form and the Expressions of Spirituality Inventory- Revised. Results: Correlations revealed that spirituality was related to DR and PTG, but not to IR or PTSD symptoms. Moderation analysis showed that spirituality significantly moderated the relationship between PTG and DR, but not the relationship between PTSD and IR. Conclusions: The findings suggest that although spirituality has no relationship with negative outcomes of trauma, it may help individuals to ruminate in a constructive manner in order to develop positive outcomes. Keywords: trauma, posttraumatic growth, posttraumatic stress disorder, rumination, cognitive processes, spirituality.

This thesis consists of two chapters, a systematic review and an empirical paper, supplemented with additional information and supporting documents that can be found in the appendices. Both chapters are intended for publication and thus have been written in the style of the identified journal for submission, The European Journal of Cancer Care. The author guidelines followed can be found in Appendix A. Recent advancements in genetic testing have led to more accurate estimations of some individuals' risks of developing breast cancer. A number of options are available for women at increased risk of this illness, defined as those who have a 30% lifetime risk of developing breast cancer due to their family history and/or to deleterious genetic mutations (National Institute of Health and Clinical Excellence, 2013). These alternatives are close surveillance using screening procedures, risk-reducing medication also known as chemoprevention, and surgical options. The latter includes risk-reducing mastectomy (RRM), the surgical removal of breast tissue with or without immediate or delayed reconstruction. There has been a notable increase in requests for RRM in recent years (Evans et al., 2015), and the knowledgebase regarding patients' decision-making continues to grow. In the United Kingdom, efforts have been made to establish guidelines for professionals working with patients who are considering RRM (British Psychological Society's Division of Clinical Psychology Faculty for Oncology and Palliative Care, 2017). Given that the choice of undergoing RRM can be complex and influenced by wideranging personal and societal factors, Chapter One aims to synthesise both qualitative and quantitative literature that explored women's views of risk-reducing breast surgery and of factors affecting their decision-making regarding this procedure, specifically when they are considering at least one other risk management alternative due to being at familial high risk of developing breast cancer. The findings of the literature review echo research within the wider literature acknowledging the multiple factors influencing patients' reasons for requesting RRM, such as risk perceptions or estimations (Fielden, Brown, Saini, Beesley, & Salmon, 2017) and psychological factors such as fear and worry about cancer (Beesley, Holcombe, Brown, & Salmon, 2013). In light of the above, Chapter Two aimed to gain a further understanding of patient's views about RRM and of how they reach their decision to opt for this procedure. Using a qualitative methodology, this study contributes to the existing research by furthering our understanding of these issues in the context of decision-making theory, highlighting that patients who are at high risk of breast cancer might reach RRM decisions heuristically.

Maladaptive perfectionism is a trans-diagnostic, multifaceted personality trait which has been associated with psychological distress. The focus of this thesis is the relationship between maladaptive perfectionism and substance use. Research to date investigating the relationship between maladaptive perfectionism and substance use has been equivocal. Therefore this thesis aimed to develop a better understanding of this relationship. To address this two papers are presented: a systematic literature review (Chapter 1) and a cross-sectional empirical paper (Chapter 2). The appendices section contains additional information relating to the two chapters. The literature review identified, collated and reported previous research in the area of perfectionism and substance misuse (alcohol and drug use). A total of 10 studies were found to be relevant after reviewing the inclusion criteria. Studies were included if they were published in English, in peer reviewed journals, used a quantitative methodology, were conducted with either adult or child populations, in community or clinical settings and reported data regarding the relationship between perfectionistic traits and substance use. The review includes a summary of the conceptualisation of perfectionism, assessment measures utilised and a synopsis of the findings from the studies. The literature to date in this area was reviewed. It was identified that perfectionism was both a risk factor and a protective factor for substance use. These conflicting findings highlighted the complex nature of perfectionism and indicated that mediating factors were influencing the relationship between the two variables. As a result recommendations for future research were proposed. Chapter 2 consists of an empirical paper. This paper drew on recommendations from the systematic review to evaluate the relationship between maladaptive perfectionism and substance use. A model was developed based on previous literature in the area and was tested using structural equation modelling. Specifically, the role of self-compassion and coping motives on maladaptive perfectionism and alcohol use were investigated. The paper also extended previous research in this area by using both implicit and explicit measures of maladaptive perfectionism. It was hypothesised that self-compassion would mediate the relationship between maladaptive perfectionism and drinking behaviour. Online self-report questionnaires and an implicit association task were completed by 89 individuals from both community and student populations. The analysis supported previous findings that maladaptive perfectionism predicts drinking to cope and results in increased alcohol consumption. It was also identified that although higher scores of maladaptive perfectionism predicted lower selfcompassion, this did not predict alcohol consumption. Exploratory analysis revealed that selfconcealment plays a role in drinking behaviour in those with high maladaptive perfectionism. Taken together, this research highlights the relationship between maladaptive perfectionism and avoidant coping strategies such as drinking to cope and self-concealment on drinking behaviour. It develops our understanding of the relationship between maladaptive perfectionism and alcohol use and presents recommendations for clinicians and future research. As the empirical paper will be submitted for publication to the Journal of Experimental and Clinical Psychopharmacology, it is written up in a style required for this.